Another explanation for the ECG, which appears to be missing some retrograde P waves?

@narrowqrs.bsky.social @shah.md @danacjohnson.medsky.social @jeffreyvinocur.bsky.social @alexturinmd.bsky.social

Ablation in this location was successful.

Strictly speaking we try to avoid pacing asymptomatic patients

Yeah I was surprised. This ECG is years ago and he actually still does not have a pacemaker!!

But then how will I know to give six units of FFP for rebalanced coagulopathy of cirrhosis 😉

My EP attending says EPs invoke superconduction and concealed conduction when they don't know what is happening 😂

I'm open to different interpretations for the changing QRS axis. I shared the ECG with a few folks and not everyone was convinced by that. What do you think explains the axis shift?

Jerry, thanks for all your detailed thoughts! Agree re: lead I, most of what I said was geared at skepticism from one person I shared the ECG with so I thought others might have similar skepticism.

I thought I had read this somewhere but I checked to make sure I wasn't just making stuff up. It was not actually from the Kosowski paper (which I thought is where I read it), it's from this one.

heart.bmj.com/content/42/4...

I also saw the rhythm start and stop with PVCs.

And this? Premature but with unchanged morphology. Concealed fusion with nearby PVC? Wobble feels unsatisfactory since cycle length is otherwise stable.

@narrowqrs.bsky.social @danacjohnson.medsky.social @shah.md @jeffreyvinocur.bsky.social @alexturinmd.bsky.social @daverichley.bsky.social

Help.

I’ve noticed this on Instagram as well.

Discussed with some rhythm friends, not everyone is convinced by superconduction. Thoughts?

Including a prior sinus-ish tracing for comparison.

@danacjohnson.medsky.social @narrowqrs.bsky.social @shah.md @jeffreyvinocur.bsky.social @alexturinmd.bsky.social @daverichley.bsky.social

My interpretation: Reverse typical flutter with dual level AVB as shown. Native complexes conduct with LAFB. R2 is Ashman beat. R4, R6 with superconduction through LAF. R8 unclear? Possible superconduction through a subdivision of LAF?