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Iatrogenic Escape-Capture Bigeminy*

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Iatrogenic Escape-Capture Bigeminy* Br Heart J: first published as 10.1136/hrt.29.2.264 on 1 March 1967. Downloaded from Brit. Heart J., 1967, 29, 264.- Iatrogenic Escape-capture Bigeminy* AGUSTIN CASTELLANOS, JR., ALBERTO BUDKIN, AND LOUIS LEMBERG From the Department of Medicine (Section of Cardiology), University of Miami School of Medicine, and the Division of Electrophysiology, Jackson Memorial Hospital, Miami, Florida, U.S.A. The primary purpose of electrical pacemakers is stimulation occurred. Initiation of pacemaking on to stimulate the heart whenever the ventricular con- demand produces escape-capture bigeminy. For tractions fail for one reason or another. In addi- instance, the fourth QRS complex is conducted from tion, there has been secondary information obtained the atria with a prolonged P-R interval. The fifth through the use of electronic equipment. Most ventricular beat is an iatrogenic escape occurring important amongst the latter has been the analogy 1'24 sec. afterward. The following P waves again between natural and iatrogenic events. Artificial capture the ventricles with a long P-R. The pacemakers have proved the importance of deduc- corresponding R-R distance is only 1 18 sec., evi- tive reasoning in clinical electrocardiography. The dently shorter than the demand escape interval. purpose of the present communication is to present Hence, it discharges the artificial pacemaker. This three examples of iatrogenic escape-capture bi- could not occur with fixed rate units. Thereafter, the geminy, a previously undescribed disorder of demand pacemaker escapes again, therefore main- rhythm, which we believe stresses the role of taining the escape-capture sequence. The same electronic instruments in understanding some funda- type of arrhythmia is seen in the upper strip of Fig. 2 mental aspects of cardiac electrophysiology. and in the first half of the bottom strip in this same illustration. Escape-capture bigeminy ends after the http://heart.bmj.com/ ESCAPE-CAPTURE BIGEMINY DURING PACEMAKING ON 5th ventricular complex when a P wave fails to cap- DEMAND ture the ventricles at an interval shorter than that pre-set for demand escapes. Since no effective car- A new type of cardiac pacemaker which works diac contraction occurs for 1 24 sec., the artificial only when required has been recently described pacemaker governs the heart. In consequence, (Lemberg, Castellanos, and Berkovits, 1965). bigeminy is substituted by a regular succession of This instrument will stimulate the heart after a pre- artificial escapes. set interval without cardiac contraction has been exceeded. It will shut itself off if, and as long as, on September 27, 2021 by guest. Protected copyright. the natural beats occur at a shorter interval than that ESCAPE-CAPTURE BIGEMINY DURING ATRIo-sYNcHRo- of pacemaker escapes. The function of this unit NIZED PACING has been described elsewhere. Various disorders of rhythm appearing after Figures 1 and 2 were obtained from a 66-year-old implantation of synchronized pacemaker were man with second degree A-V block alternating with described in a previous communication. At that periods of complete A-V block. The upper strip time we had not yet observed escape-capture big- in Fig. 1 shows sinus rhythm and 3:2 A-V block with eminy during the use of this effective form of the Wenckebach phenomenon. The P waves are cardiac pacemaking (Castellanos and Lemberg, not well delineated in the bipolar chest leads used 1964). for cardiac monitoring. The patient was paced by The upper strip in Fig. 3 was obtained after im- means of a right ventricular catheter electrode con- plantation of this unit in a patient with advanced nected to a portable demand pacemaker. In the A-V block. The P waves trigger the pacemaker bottom strip the artificial unit was set to escape if an after an atrio-pacemaker conduction time of0-20 sec. interval of 1 '24 sec. without effective ventricular The pacemaker in turn depolarizes the ventricles. Received March 18, 1966. The sino-atrial rate is 94 a minute. The same se- * Aided by a Grant from the Heart Association of Greater quence of events occurs in the first complex of the Miami. bottom strip. At this moment, however, the sinus 54 Br Heart J: first published as 10.1136/hrt.29.2.264 on 1 March 1967. Downloaded from Jatrogenic Escape-capture Bigeminy 265 .. .Jf.l Iii~~~~~~~~~~~~~~~~. b.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ .. j~~~~~~~~~~~~~~~~~~~~~~~~" FIG. Escape-capture bigeminy inu pperth p cha ngion a successionc ofaescapes adu Ing onri showsiushyt m wth 32 AV demandit (lowerbsrip LheadeoeItrpsowIsae-atr. o http://heart.bmj.com/ on September 27, 2021 by guest. Protected copyright. .t .....7. --- .. ..... ~~~~rI~~~~~~~II TI?'] 1! 1 5'~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..... FIG. 3.-Escape-capture bigeminy during the operation of an atrio-synchronized pacemaker (see tent). Lead IL. Br Heart J: first published as 10.1136/hrt.29.2.264 on 1 March 1967. Downloaded from 266 Castellanos, Budkin, and Lemberg rate has increased to 102 a minute. In consequence the atria, whereas in escape-capture bigeminy the P the second P wave reaches the pacemaker during wave is generally of normal morphology since the the refractory period of the latter. Hence it cannot stimulus producing it originates in the sinus node. be conducted to the ventricles through the artificial The arrhythmia under consideration is known to bypass (conduction through the normal junction is be originated by disturbances in impulse conduction. also impossible due to the presence of apparently The original case reported by Bradley and Marriott complete A-V block). This instrument has also a (1958) was produced by 2:1 sino-atrial block. built-in escape safety mechanism. In this case it Digitalis was probably a causal factor. Escape- was set to escape if a pause of 1 10 sec. without a capture bigeminy disappeared when normal S-A cardiac contraction occurred. This feature explains conduction returned. Schamroth and Dubb (1965) the escape taking place before the third P wave is published cases of escape-capture bigeminy ori- able to activate the ventricles via the pacemaker. ginated by 2:1 S-A block; 3:1 A-V block; and re- On the contrary, the fourth P wave occurs farther versed reciprocal rhythm. These authors intro- away from the QRS complex than the "blocked" duced the concept of "effective intersinus interval" one, well after the end of the refractory of the iatro- defined as the interval between sinus impulses at genic A-V junction. For this reason it can be the level of the lower (escaping) pacemaker. They conducted to the ventricles. Escape-capture bi- pointed out that this interval had to exceed the sum geminy was thus initiated. In this case it persisted of the refractory period of the escape beat plus its until the sinus rate decreased spontaneously, thus escaping time if the escape-capture rhythm was to allowing for the return of 1:1 atrio-pacemaker occur. Sinus bradycardia was not considered a conduction. fundamental cause of this arrhythmia, mainly be- cause it is difficult to determine whether a slow sino- ESCAPE-CAPTURE BIGEMINY OCCURRING AFTER CAR- atrial rhythm is due to a slow rate of impulse forma- DIOVERSION tion or to sdme degree of sino-atrial block. The top The term escape-capture sequence was coined strip in Fig. 4 shows widened and bizarre QRS com- by Bradley and Marriott in 1958 in order to define plexes occurring at a rate of 230 a minute. In the the electrocardiographic pattern produced by an absence of cesophageal leads the arrhythmia could be escape beat followed by a normally conducted sinus interpreted either as ventricular tachycardia, A-V impulse. When this sequence repeats itself re- nodal tachycardia with aberration, or atrial flutter 1:1 A-V conduction and aberrant ventricular sulting in a stable rhythm, it is called escape-capture with http://heart.bmj.com/ bigeminy, since pairing of beats in bigeminal conduction. The exact nature of the disorder of arrangement results. This rhythm has been called rhythm is not important in relation to the events also "pseudo-reciprocal" due to its similarity to which followed a synchronized DC shock of 200 those produced by reciprocal mechanisms. The watt-second. The middle strip was recorded a few difference lies then in the latter; the P wave seconds after cardioversion. The first P wave is appears inverted in leads where it is usually conducted with a normal P-R interval. It is upright (II-III-aVF) due to retrograde activation of followed by an A-V nodal escape which depolarizes on September 27, 2021 by guest. Protected copyright. 200 watt-sec FIG. 4.-Escape-capture bigeminy appearing during a period of post-cardioversion sinus bradycardia. Top strip shows widened and bizarre QRS complexes at 230 a minute, the interpretation being tachycardia of inde- terminate origin. Middle and lower leads recorded after conversion by DC counter-shock, showing brady- cardia followed by escape-capture bigeminy. Br Heart J: first published as 10.1136/hrt.29.2.264 on 1 March 1967. Downloaded from Iatrogenic Escape-capture Bigeminny 267 the ventricles after a long pause without detectable behaviour of naturally occurring disturbances in atrial activity. The second P wave stimulates the impulse formation and impulse conduction is fully ventricles soon after the escape, and establishes the comprehended (Castellanos and Lemberg, 1964). sequence of escape-capture bigeminy initiated ap- Advances in the recently introduced field of iatro- parently by a sinus node effectively discharging at a genic electrical arrhythmias have corroborated the rate of around 35 a minute (sinus bradycardia). importance ofthe deductive reasoning made for more The fourth P wave falls in the refractory period of than 40 years by clinical investigations of the arrhy- the preceding escape (due to sinus arrhythmia), thmias. Disorders of rhythm appearing after the therefore being ineffective in stimulating the use of the more sophisticated electronic equipment ventricles.
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