08/12/2017 What Is Happening in This Tracing?

What Is Happening in This Tracing?

Kyuhyun Wang, MD
DISCLOSURES | September 13, 2013

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These are rhythm strips from the same patient in a span of 5 minutes. What is
happening? Choose one from the list below?
Your Peers Chose:

1° and type I and II 2° AV block

57%

Pseudo AV block due to concealed premature junctional

43%
beats

Answer
Pseudo AV block due to concealed premature junctional beats

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08/12/2017 What Is Happening in This Tracing?

Figure 2.

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08/12/2017 What Is Happening in This Tracing?

Figure 3.

Discussion
In figure 1, the 4th beat in tracing (a) suddenly has a longer PR interval than the others. The
findings in tracing (b) suggest AV Wenckebach phenomenon (type I 2° AV block). The findings
in tracing (c) suggest type II 2° AV block. Type I and type II 2° AV block, however, does not
occur in the same patient in a span of 5 minutes. What is happening is revealed in the tracing
(d). The 5th beat is a premature junctional complex (PJC) with a slight aberrant conduction.

What is happening is diagrammed in figure 2. This patient has frequent PJCs. If a PJC occurs
early enough, when the atria and the AV or ventricular conduction system are refractory, it
won't cause either a retrograde P wave or QRS; Thus, there is no trace of this PJC (it is
completely hidden from the surface ECG), hence this phenomenon is called concealed
conduction. However, the PJC is affecting the conduction of the subsequent beat by rendering
the AV conduction system relatively refractory, causing the PR to be prolonged (situation 1,
pseudo 1° AV block). If the PJC occurs a bit later, it may collide with the impulse from the sinus
P wave and then AV dissociation results, but still too early to conduct to the ventricles; a sinus
P wave will stand alone (situation 2, pseudo type II 2° AV block, tracing c). If situations 1 and 2
occur sequentially, the result is pseudo type I 2° AV block (tracing b). This is verified by the His

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08/12/2017 What Is Happening in This Tracing?

bundle recording as shown in figure 3 (A: atrial depolarization; H: His bundle depolarization
from the sinus impulse; H': His bundle depolarization from PJC; V: ventricular depolarization).

Thus, a given tracing can be dissected into a primary disorder and secondary manifestations,
which will help provide proper treatment. In this patient, the primary disorders, or the culprits,
are frequent PJCs, which are benign, and the secondary manifestations are various pseudo AV
block, so a pacemaker is not required.

Medscape Cardiology © 2013 WebMD, LLC

Cite this article: What Is Happening in This Tracing? - Medscape - Sep 13, 2013.

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