R-on-T Ventricular Fibrillation
Report:
Sinus tachycardia
Second degree AV block
VEBs
Bigeminy
R-on-T phenomenon
Ventricular fibrillation
ST segment elevation consistent with epicardial injury
Comment:
The VEB with the shortest coupling interval initiates VF. It comes right on top of the T wave; all the others occur just after the peak. The significance of this, traditionally fearful, phenomenon remains uncertain vis à vis VEBs occurring later30. Similarly, the significance of primary VF in acute MI continues to be redefined120.
The Cardiologistâs report of âMöbitz 2â and â4:1 A-V blockâ is remarkable. It must have been in a context like this when an Englishman said: The Americans scare me: they are so knowledgeable!
It is interesting to observe the doubling of the âblockâ due to the VEBs. In the single cycle without a VEB, at the end of the top strip, the block is clearly 2:1. VEBs causing advanced AV block de novo are shown in Case 202.
It has never been established whether one should, conventionally, report first degree AV block in the presence of a second degree one. It feels pedantic; I do not do it routinely. In this example, it points to the AV nodal site of the block (Möbitz 2 report notwithstanding) - hardly necessary in the presence of narrow QRS and acute inferior infarction. As the conduction ratio improves this patient would be expected to reveal Wenckebach AV block.
146. A temporary bipolar pacemaker (spikes invisible) has been inserted and set at 49/min. The patient was a 77 year old man with chest pain and syncope.
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