ECG - Modul 4

Blocurile AV sau joncţionale

 Learning Modules
• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
 Arrhythmias
• Sinus Rhythms
• Premature Beats
• Supraventricular Arrhythmias
• Ventricular Arrhythmias
• AV Junctional Blocks
 Traseul 1

Prezentă, normală
• Unda P?

• Distanţele RR? Egale, regulate

0.36 s, prin creşterea
• Intervalul PR?
segmentului PQ (0,28 s)
• Frecventa ? 60 bpm

Interpretare? Bloc AV de gradul I

Explorări Funcţionale
 Bloc AV de gradul I - suport teoretic

• Deviaţie de la ritmul sinusal

• Întârzierea transmiterii stimulului de la atrii la ventriculi, la
nivelul NAV sau, mai rar, la niv. fasciculului His
• EKG: alungirea constantă a intervalului PQ peste valoarea
normala de vârstă şi frecvenţă (peste 0,20 sec.).
• Cauze:
 congenitale;
 fiziologice (hipervagotonie);
 patologice: IMA inferior, cardita reumatismala, ischemie miocardica,
supradozaj de digitala, propranolol, verapamil etc.
Explorări Funcţionale
NOTĂ: La finalul interpretării trebuie precizat ritmul. Pentru situaţia
de mai sus:
Ritm sinusal cu bloc AV de gradul 1

Explorări Funcţionale
 Traseul 2

• Unda P? Normală, dar a 4-a nu este

urmată de QRS
• Distanţele RR? Neregulate
• PR interval? Alungit treptat
• Frecvenţa? 60 bpm
• Durata QRS? 0.08 s
Interpretare? Bloc AV, Tip Mobitz I cu
perioade Luciani-Wenckebach
Blocul AV Block, Tipe Mobitz I cu perioade Luciani-
Wenckebach

• Deviatie de la ritmul sinusal

• PR se alungeste treptat, până când un impuls este
complet blocat şi unda P nu este urmată de QRS.
• Etiologie: fiecare impuls atrial suferă o întârziere din
ce în ce mai mare în nodulul AV (bloc parţial), până
când un impuls atrial, de regulă al 3-lea sau al 4-lea
este complet blocat (bloc total).
Explorări Funcţionale
Blocul AV Block, Tip Mobitz I cu perioade Luciani-
Wenckebach

Causes of Wenckebach Phenomenon

• Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
• Increased vagal tone (e.g. athletes)
• Inferior MI
• Myocarditis
• Following cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)
Clinical Significance of AV Block: 2nd degree, Mobitz I
• Mobitz I is usually a benign rhythm, causing minimal haemodynamic
disturbance and with low risk of progression to third degree heart block.
• Asymptomatic patients do not require treatment.
• Symptomatic patients usually respond
Explorări to atropine.
Funcţionale

• Permanent pacing is rarely required.

Explorări Funcţionale
• Sinus rhythm with acute inferior infarction complicated by Type I A-V block
manifest in the form of 5:4 Wenckebach periods; R-P/P-R reciprocity.
Explorări Funcţionale
Explorări Funcţionale
 Traseul 3

• Unda P? Normală, dar undele p 2,3,5,6…nu

sunt urmate de QRS
• Distanţele RR? regulate
• Intervalul PR? 0,14 sec.
• Frecvenţa? 40 bpm
• Durata QRS? 0,08 s
Interpretare? Bloc AV, Tip Mobitz II
Explorări Funcţionale
 Bloc AV, Tip Mobitz II
• Tulburare de conducere - deviaţie de la ritmul sinusal
• Intermittent non-conducted P waves without progressive prolongation of the PR
interval.
• The PR interval in the conducted beats remains constant.
• The P waves ‘march through’ at a constant rate.
• The RR interval surrounding the dropped beat(s) is an exact multiple of the
preceding RR interval (e.g. double the preceding RR interval for a single dropped
beat, treble for two dropped beats, etc).
• Mechanism. Mobitz II is usually due to failure of conduction at the
level of the His-Purkinje system
• While Mobitz I is usually due to a functional suppression of AV conduction (e.g.
due to drugs, reversible ischaemia), Mobitz II is more likely to be due
to structural damage to the conducting system (e.g. infarction, fibrosis, necrosis).
• In around 75% of cases, the conduction block is located distal to the Bundle of
His, producing broad QRS complexes.
• In the remaining 25% of cases, the conduction block is located within the His
Bundle itself, producing narrow QRS complexes.
 Bloc AV, Tip Mobitz II

• tip Mobitz II – segment PQ cu durată normală sau crescută, fixă,

constantă, dar în mod izolat, nesistematizat, un stimul este blocat: între
două unde P lipseşte răspunsul ventricular (QRS).
• RR - neregulate

• Tip Mobitz II cu relaţie fixă – blocarea transmisiei stimulilor prin

NAV este sistematizată, de tip 2:1 sau 3:1. (Doi stimul pornesc din
NSA, unul se pierde, unul se transmite; trei stimului pornesc, unul se
transmite, etc.)
• RR - regulate
Explorări Funcţionale
• Sinus rhythm (rate = 100/min) with 3:2 and 2:1 Type II A-V
block; RBBB Explorări Funcţionale
 Traseul 4

• Unda P? Există, dar nu are relaţie cu

QRS
• Distanţele RR? Egale, regulate
• Intervalul PR? Nu poate fi determinat
• Frecvenţa? 30 bpm
• Durata QRS? mare (> 0.12 s)
Interpretatare? Bloc AV de gradul 3
Explorări Funcţionale
Complete Heart Block (CHB)
• In complete heart block, there is complete absence of AV conduction –
none of the supraventricular impulses are conducted to the ventricles.
• Perfusing rhythm is maintained by a junctional or ventricular escape
rhythm. Alternatively, the patient may suffer ventricular standstill
leading to syncope (if self-terminating) or sudden cardiac death (if
prolonged).
 Bloc AV de gradul 3

• Deviatie de la ritmul sinusal

– Unda P este complet blocată în joncţiunea AV;
– Atriile şi ventriculii funcţionează independent:
atriile în ritm sinusal, ventriculii în ritm
idioventricular
– QRS se formează independent într-un pace-maker
ventricular:
• QRS este lărgit şi cu morfologie modificată, bizară;
• Frecvenţa cardiacă: 30 –45 bpm
Explorări Funcţionale
Explorări Funcţionale
 Remember
• Când un impuls este generat în ventriculi,
conducerea este lentă şi alterată, consecinţa
fiind un complex QRS larg şi cu morfologie
modificată.
Explorări Funcţionale
 SEGMENTUL PQ sau PR
Scurtarea segmentului PQ = Conducerile accelerate al caror suport este
reprezentat de prezenta fasciculelor aberante de conducere - Palladino-Kent, James si
Mahaim.

▪ Prezenta fasciculului Palladino-Kent determina aparitia sindromului Wolff - Parkinson-

White – WPW caracterizat prin scurtarea intervalului PQ pe seama segmentului PQ si
aparitia undelor delta (δ) la nivelul complexului QRS, motiv pentru care complexele sunt
deformate si au o durata mai mare

By-pass atrio-ventricular drept sau stâng

▪ Lipsa segmentului Pq
▪ Deformarea QRS prin prezenţa undei delta dată de depolarizarea ventriculară
pe căi ephaptice

▪ Fasciculul James duce la aparitia sindromului Lown-Ganong-Levine - LGL caracterizat de

scurtarea segmentului PQ, complexele QRS fiind normale

By-pass atrio-nodal: Lipsa segmentului PQ; Complex QRS normal

▪ Fasciculul Mahaim - - By-pass His- Purkinje

apare unda delta, segmentul PQ este normal
 Sindromul Wolff - Parkinson-White – WPW
• Pre-excitation refers to early activation of the ventricles due to impulses
bypassing the AV node via an accessory pathway.
• Accessory pathways, also known as bypass tracts, are abnormal conduction
pathways formed during cardiac development and can exist in a variety of
anatomical locations and in some patients there may be multiple pathways
• In WPW the accessory pathway is often referred to as the Bundle of Kent, or
atrioventricular bypass tract.
• An accessory pathway can conduct impulses either anterograde, towards the
ventricle, retrograde, away from the ventricle, or in both directions.
• The direction of conduction affects the appearance of the ECG in sinus rhythm
and during tachyarrhythmias.
• Tachyarrythmia can be facilitated by the formation of a reentry circuit involving
the accessory pathway, termed atrioventricular reentry tachycardias (AVRT).
• Tachyarrythmia may also be facilitated by direct conduction from the atria to
the ventricles via the accessory pathway, bypassing the AV node, seen with
atrial fibrillation or atrial flutter in conjunction with WPW

» https://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/
 Re-entry circuit during AVRT (retrograde
conduction via Bundle of Kent)

• ECG features of WPW in sinus rhythm are:

• PR interval <120ms
• Delta wave – slurring slow rise of initial portion of the QRS
• QRS prolongation >110ms
• ST Segment and T wave discordant changes – i.e. in the opposite direction to the
major component of the QRS complex
• Pseudo-infarction pattern can be seen in up to 70% of patients – due to negatively
deflected delta waves in the inferior / anterior leads (“pseudo-Q waves”), or as a
prominent R wave in V1-3 (mimicking posterior infarction).
• Sinus rhythm with a very short PR interval (< 120 ms).
• Broad QRS complexes with a slurred upstroke to the QRS complex — the delta wave.
• Dominant R wave in V1 — this pattern is known as “Type A” WPW and is associated with a left-sided accessory
pathway.
• Tall R waves and inverted T waves in V1-3 mimicking right ventricular hypertrophy — these changes are due to
WPW and do not indicate underlying RVH.
• Negative delta wave in aVL simulating the Q waves of lateral infarction — this is referred to as the “pseudo-
infarction” pattern.
• Atrial fibrillation in a patient with WPW:
• Rapid, irregular, broad complex tachycardia (overall rate ~ 200 bpm) with a LBBB
morphology (dominant S wave in V1).
• This could easily be mistaken for AF with LBBB.
• However, the morphology is not typical of LBBB, the rate is too rapid (up to 300 bpm in
places, i.e. too rapid to be conducted via the AV node) and there is a subtle beat-to-beat
variation in the QRS width which is more typical of WPW (LBBB usually has fixed width QRS
• LGL syndrome:
• Very short PR interval.
• Narrow QRS complexes.
• No evidence of delta waves.
• Complete Trifascicular Block:
• Right bundle branch block
• Left axis deviation (Left anterior fascicular block)
• Third degree heart block
• Incomplete Trifascicular Block:
• Right bundle branch block
• Left axis deviation (= left anterior fascicular block)
• First degree AV block

• https://lifeinthefastlane.com/ecg-library/basics/left-ventricular-hypertrophy/