Cases reported "Heart Block"

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1/18. Alternating reversed wenckebach periodicity: Concealed electrotonic conduction as a possible mechanism.

    Electrocardiograms were taken from a 67-year-old man with 2:1 atrioventricular block in whom alternating reversed Wenckebach periodicity was found. Long PR intervals of alternately conducted P waves progressively shortened until an alternate P wave was blocked. After an alternate P wave was blocked, the next alternate P wave was conducted to the ventricles with a markedly long PR interval. Then long PR intervals of alternately conducted P waves progressively shortened again until an alternate P wave was blocked. This is the first report on alternating reversed Wenckebach periodicity. It seems that concealed electrotonic conduction of alternately blocked impulses occurred as a possible mechanism.
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2/18. Neurocardiogenic syncope in chronic atrioventricular block.

    We report a 37-year-old man with type I second-degree atrioventricular (AV) block (atypical Wenckebach's periodicity) referred to our department for pacemaker implantation because of an episode of syncope. After exhaustive evaluation, including electrophysiological test, in which Wenckebach's cycles with block within the AV node was demonstrated, syncope was considered to be neurally mediated. head-up tilt testing with sublingual isosorbide dinitrate was positive. The decrease in atrial rate at the beginning of the vasovagal reaction was not immediately accompanied by a depressed AV node conduction. Only at the moment of syncope did incomplete AV block appear. This observation illustrates (1) a neurally mediated origin of syncope in a patient with chronic AV block, and (2) the different time-course responses of the sinus and AV nodes to autonomic tone.
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3/18. Intermittent ventricular bigeminy as an expression of two-level Wenckebach periodicity in the reentrant pathway of extrasystoles.

    A patient with intermittent ventricular bigeminy is reported in whom the presence of two-level Wenckebach periodicity in the reentrant pathway of extra-systoles is suggested. When sinus arrest was caused by vagal stimulation, no ectopic QRS complex occurred. This indicated that ventricular bigeminy was not parasystolic bigeminy but ordinary extrasystolic bigeminy. Observations of the electrocardiogram suggested that Wenckebach block occurred at two different levels in the reentrant pathway of ventricular extrasystoles. When extrasystoles were noninterpolated, Wenckebach block occurred at the distal level of the pathway and caused termination of ventricular bigeminy. On the other hand, when extrasystoles were interpolated, Wenckebach block occurred at the proximal level of the pathway. This is the first report to suggest the presence of two-level Wenckebach periodicity in a reentrant pathway of extrasystoles.
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4/18. Periodic changes in cycle length of ventricular tachycardia: a Wenckebach type exit block?

    A 55-year-old female developed ventricular tachycardia (VT) which showed a Wenckebach periodicity in cycle length. She had had a myocardial infarction about ten years previous and, at age 51, felt fatigability and palpitations. The ECG showed VT. Thereafter, she had had palpitations of short duration two to three times a year. On the last admission she developed fatigability; the ECG showed VT. lidocaine (100 mg i.v.) did not terminate VT. procainamide (600 mg) could not terminate the VT, but the rate became slower. Programmed stimulation was given at bedside which effectively terminated VT. Electrophysiologic study induced VT in a reproducible manner. Ventricular tachycardia showed initial fluctuation in cycle length which stabilized at 270 msec. disopyramide therapy (400 mg/day p.o.) was begun and electrophysiologic study was repeated one week later. VT was again induced but the cycle length was a little longer. A periodic change in cycle length from 328 to 442 msec was repeated. The change in cycle length was uniformly found in surface leads (I, II, V1) and intracardiac electrograms from the right ventricular apex and the His bundle region. No change in QRS complex was found and the periodicity was unrelated to atrial activity. A Wenckebach type exit block was therefore suggested; disopyramide might be responsible for the development of the block. We could not find another such case in the literature.
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5/18. Type A alternating Wenckebach periodicity in the reentrant pathway of interpolated ventricular extrasystoles.

    A 67-year-old man with interpolated ventricular extrasystoles is reported in whom alternate sinus QRS complexes were followed by interpolated ventricular extrasystoles with progressively lengthening coupling intervals until one of these alternate sinus complexes failed to be followed by an extrasystole. This is the first report to suggest the presence of type A alternating Wenckebach periodicity in the reentrant pathway of interpolated ventricular extrasystoles. It is suggested that 2:1 block occurred at a proximal level in the reentrant pathway, while Wenckebach block occurred at a distal level in the pathway.
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6/18. Permanent form of junctional reciprocating tachycardia with only even-numbered beats.

    An analysis of the electrocardiogram of a patient with the permanent form of junctional reciprocating tachycardia is presented. The patient demonstrated near-incessant tachycardia, with a 1:1 atrioventricular relationship and a retrograde P wave (P') occurring closer to the succeeding QRS complexes (ie, with a P'R interval that is shorter than the RP' interval). Each tachycardia episode was characterized by alternating short and long cardiac cycles due to alternation of retrograde conduction time (RP' interval), retrograde Wenckebach periodicity, and an even number of ectopic P' waves. The authors propose that there is an accessory AV connection with decremental functional properties that arborizes into two atrial branches with different conduction times. The fast branch initially exhibits a 3:2 retrograde conduction block followed by a cycle length-dependent 2:1 retrograde conduction block, thereby permitting alternate use of the slow branch, which is the weakest component of the reciprocating process.
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7/18. The electrocardiographic manifestation of combined AV nodal Wenckebach periodicity and reentry.

    Presented are three patients with Wenckebach type second degree AV block that was complicated with AV nodal reentry producing different arrhythmias. The common presentation of manifest AV nodal reentry is an incomplete Wenckebach periodicity, whereby the retrograde impulse interrupts the Wenckebach cycle; rarely, the retrograde impulse initiates an AV junctional reentrant tachycardia. The documentation of concealed AV nodal reentry is more difficult and should be considered if there is a sudden increase of the PR interval in the Wenckebach cycle.
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8/18. Atrial tachycardia, 2:1 alternate Wenckebach periodicity, and atrial standstill.

    A case of atrial tachycardia, 2:1 alternate Wenckebach periodicity and atrial standstill is reported in an 80-year-old woman who complained of exertional dyspnea and occasional syncope for two years. Two blocked P' waves appeared after each Wenckebach period suggesting type B alternating Wenckebach phenomenon (Mobitz type II 2:1 A-V block distal, and Wenckebach conduction proximal).
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9/18. Atrial pacing-induced alternating Wenckebach periodicity and multilevel conduction block in children.

    Multilevel block within the atrioventricular (AV) node has not been previously described in children. Six children with atrial pacing-induced repetitive block are presented. The conduction patterns satisfy the requisites for alternating Wenckebach periodicity or multilevel AV block. In 2 patients the block is documented in the AV node and infra-His region. In 4 patients multilevel block within the AV node is postulated by deductive reasoning. In this study, 2 patterns of alternating Wenckebach periodicity are reported for the first time: sequences of 3:1 block with progressive prolongation of the conducted impulses terminating in 4:1 block; and sequences of 2:1 block with progressive prolongation of the conducted impulses terminating in 2 series of 3:1 block, in which the first conducted impulse following the first 2 blocked beats is not the shortest one, whereas that following the second 2 blocked beats is the shortest.
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10/18. Type A alternating Wenckebach periodicity in the re-entrant path of ventricular extrasystoles.

    A patient with ventricular extrasystoles is reported in whom Type A alternating Wenckebach periodicity in the re-entrant path of the extrasystoles is suggested for the first time. Namely, it appears that 2:1 exit block occurs at a proximal level in the re-entrant path and block of the Wenckebach form occurs at a distal level in the path. The presence of three-level block in the re-entrant path is also suggested in this patient.
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