Ventricular arrhythmias

Categories
Premature Ventricular Complex (PVC) Unifocal Multifocal Couplets Bigeminy Ventricular Parasystole Fusion Complexes Ventricular escape rhythm Accelerated idioventricular rhythm Ventricular tachycardia
Non-sustained Monomorphic VT Polymorphic VT Torsades de pointes

Ventricular fibrillation

Premature Ventricular Complex (PVC)

ECG characteristics: Premature in relation to the expected beat of the basic rhythm QRS complex is abnormally wide Secondary ST-T changes Full compensatory pause often follows PVC Retrograde P wave due to retrograde ventriculo atrial conduction may appear VPCs originating in the same focus ( unifocal ) have constant coupling interval VPCs originating in the same focus do not necessary have the same morphology

Premature Ventricular complex

Premature Ventricular Complex : Unifocal

Premature Ventricular complex : Multifocal

Ventricular Couplet

Ventricular Triplets, monomorphic

Ventricular Bigeminy: QRS +ve in V1

Ventricular bigeminy is generally a benign rhythm

Ventricular Bigeminy: QRS -ve in V1

Ventricular parasystole
Ectopic ventricular pacemaker activates concurrently with the basic rhythm Ventricular impulse independent of basic rhythm
ECG characteristics:

Varying coupling interval

RR of PVCs are mathematically related with each other The presence of fusion beats

Ventricular parasystole

Fusion/Capture complex
Ventricular impulse discharges at the time the atrial rhythm arrives at the ventricles Ventricle depolarized by two activation fronts and a fusion beat is produced Morphology intermediate between atrial rhythm complex and ventricular complex Seen in all types of ventricular arrhythmias Occur more commonly with ventricular parasystoles

Fusion/Capture complex

Wide complex tachycardia with fusion complex (arrows)

Ventricular escape rhythm

A wide QRS (RBBB-like) escape rhythm in a patient with complete AV block

Accelerated idioventricular rhythm

(AIVR) Also called non-paroxysmal ventricular tachycardia Commonest in acute myocardial infarction, especially after thrombolysis Normal variant, especially in younger patients with increased vagal tone
ECG characteristics supporting AIVR: Has most of the characteristics of ventricular tachycardia, but slower ventricular rate Rhythm called accelerated because rate greater than inherent rate of ventricular pacemakers Ventricular rate between 60 and 110 bpm Rhythm is regular Abnormal wide QRS complexes

Accelerated idioventricular rhythm

Note the underlying AV block (*)

Accelerated idioventricular rhythm

The underlying setting is of a recent inferior wall M.I. The AIVR gradually sets in and later self-terminates

Ventricular Tachycardia (VT)

Sustained
lasting > 30 seconds

Nonsustained
lasts 30 seconds or less
ECG characteristics supporting VT: Abnormal wide QRS with secondary ST-T changes, at least three ventricular complexes in succession Ventricular rate > 100 BPM Rhythm is regular or slightly irregular Abrupt onset and termination AV dissociation is often present Capture beats may occur Fusion beats may occur

Monomorphic ventricular tachycardia

Ventricular rate
Abnormal wide QRS with secondary ST-T changes, at least three ventricular complexes in succession Ventricular rate > 100 BPM Rhythm is regular or slightly irregular usually between 140 - 200 BPM occasionally 120 BPM

Nonsustained repetitive monomorphic ventricular tachycardia

Nonsustained ventricular tachycardia

Sustained monomorphic ventricular tachycardia

Bidirectional VT
Patient had aconite toxicity from homeopathic medication

Polymorphic VT
Causes
Acute ischemia Dysmetabolic state especially low serum K+ levels

Ventricular rate
Abnormal wide QRS with secondary ST-T changes, at least three ventricular complexes in succession Ventricular rate between 200-250 bpm Irregular Rhythm Two or more cycles of QRS complexes with alternating polarity TdP: QT prolongation in basic rhythm with typical morphology of polymorphic VT

Polymorphic VT
During a stress test .

Torsades de pointes (TdP)

TdP: QT prolongation in basic rhythm with typical morphology of polymorphic VT

Torsades refers to an ornamental motive imitating twisted hairs or threads as seen on classical architectural columns, andpointes refers to points or peaks
A circular detachable hair band that could be twisted to demonstrate how the points of the teeth and the intermediary gap simulated the pointed side and the broad side, respectively, of the asymmetrical electrocardiographic waves that formed the TdP

Torsades de pointes

Incessant nonsustained torsades de pointes, in a patient early after mitralvalve surgery.

Cardiac arrest
Ventricular Fibrillation Cardiac arrest 80%

Flat
Asystole 20% P waves

Chous Electrocardiography in clinical practice, 6th ed,2008

Ventricular fibrillation (VF)

Ventricular rate
Irregularly Irregular Rhythm Consists of chaotic deflections of varying amplitude and contour No definite P waves, QRS complexes or T waves can be recognized Rate of undulations vary between 150-500 bpm

Ventricular fibrillation

Polymorphic VT - VF
Termination by DC shock

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