Onset of Multiform VT

Report:

Sinus tachycardia 110/min

Intraventricular conduction delay, probably RBBB

VEBs, possibly fusion beats

Small voltage in frontal leads

Multiform ventricular tachycardia 160 – 290/min

Comment:

First, third and sixth beats may be fusion beats, associated with shorter PR intervals. The VT starts with the sixth beat, from a late-diastolic, likely fusion, VEB.

The paroxysm attains great speed and irregularity, presaging VF, but slows down to more constant morphology in the last three beats on the recording. The patient was virtually pulseless and had to be electroverted about 40 times before coming to ICU! Multiple antiarrhythmic drugs and belated streptokinase failed, but t-PA produced a gratifying reduction in ST segment elevation and cessation of the arrhythmias (Fig 103a below). Even the conduction defects disappeared, temporarily. Anterior and inferior infarction showed their Q waves.

At other times, before the tracing in 103a, this patient had LBBB as well as RBBB – a real BBBB (only RBBB and hemiblocks shown in Figs 103b, c and d below; the LBBB recording is now lost). He died in cardiogenic shock within 24 hours. This is how it happens, nowadays. Not from arrhythmias, not from conduction system disease, but from loss of myocardium.

Qui cito dat, bis dat. Earlier thrombolysis could have helped. 103a. Not much left, after 70 or more countershocks.

103b. Earlier ECG in sinus tachycardia, with RBBB tombstones.

103c. Evolving infarction, two hours after recording in Fig 103b. There is an LAHB added to RBBB. V4-5 complexes look, prophetically, like volcanoes.

103d. Atrial rhythm, possibly sinus, with RBBB and new LPHB.