Acute Infarction with Pre-existing LBBB

Report:

Sinus rhythm 60/min

Left atrial abnormality (LAA)

Left bundle branch block

Acute inferior & anterior infarction

Comment:

The diagnosis was based on new and marked ST segment elevation in the inferior leads and V3 as well as concordant T inversion (a primary repolarisation change in LBBB) in V4.

The patient had left main disease and shock but his aorta was too calcified for grafting or (anticipated) counterpulsation; the Cardiologist elected to do primary angioplasty. The outcome was good, except that the cardiac surgeons became angry they were not asked to make the decision themselves. It must have been situations like this that prompted the now cliché aphorism14 ars longa, vita brevis, occasio præceps, experimentum periculosum, iudicium difficile. Most of it applies on how to deal with surgeons.

The next day the ECG reverted to its previous shape, except for the still suspicious repolarisation in V5 (below, Fig 19a).

19a. V5 still looks “abnormal” (for LBBB). 20. Hypotensive 43 year old man with chest and jaw pain.