Sinus escape-capture bigeminy alternating with sinus extrasystolic bigeminy: dual atrial response and apparent sinus escape.

We report here five cases of sinus bigeminy in which comparatively long PP intervals alternated with comparatively short PP intervals, suggesting 'sinus escape-capture bigeminy' or 'sinus extrasystolic bigeminy'. In three of the cases, these two forms of sinus bigeminy were found in the same patient. This is the first study on 'sinus escape-capture bigeminy' alternating with 'sinus extrasystolic bigeminy'. The electrocardiographic findings in these cases suggest the possibility that 'sinus escape' in the sinoatrial junction is not true escape. Attempts are made to explain that apparent sinoatrial junctional escape occurs as a result of markedly slow conduction through the slow sinoatrial pathway, using the concepts of 'dual sinoatrial pathways' and 'double atrial response'.

Parasystole due to re-entry as the possible mechanism of ventricular parasystole with second-degree entrance block.

BACKGROUND: In 1974, Kinoshita reported a case of 'irregular parasystole' due to type I second-degree entrance block. Since then, many cases of such 'irregular' parasystole have been reported by us. To explain the mechanism of 'irregular' parasystole, two theories have been suggested, namely, 'electrotonic modulation' by Jalife and Moe, and 'type I second-degree entrance block' by us. On the contrary, in 1960, Kinoshita et al. reported a case of concealed bigeminy for the first time. The electrocardiographic findings in concealed bigeminy have suggested that there are dual re-entrant pathways with markedly long effective refractory periods in the re-entrant pathway. We have suggested that parasystole may be caused by re-entry in such re-entrant pathways. In this article, attempts are made to explain the mechanism of all the electrocardiographic findings in our cases of parasystole by 'parasystole due to re-entry'. METHODS: Using 24 studies on parasystole and 21 studies on concealed extrasystoles that we have reported over 50 years, as well as three exemplary cases in this article, attempts are made to explain all electrocardiographic findings in parasystole by 'parasystole due to re-entry'. CONCLUSIONS: The electrocardiographic findings in our previous clinical cases of parasystole and concealed extrasystoles, as well as exemplary cases and diagrams in the present article, strongly suggest 'parasystole due to re-entry' as the mechanism of ventricular parasystole with second-degree entrance block.

Apparent AV junctional escape in Wenckebach AV block: markedly slow conduction through the slow AV pathway.

We report here two cases of Wenckebach atrioventricular (AV) block in which apparent AV junctional escape was observed, but most likely resulted from markedly slow conduction through the slow pathway of dual AV junctional pathways. In these cases, it seems that a blocked P-wave was followed by an AV junctional escape beat. However, a blocked P-wave occasionally failed to be followed by an escape beat, and the RR interval containing the blocked P-wave was markedly longer than the above escape interval. In one case, apparent AV junctional escape beats with aberrant ventricular conduction were found, and QRS complexes of the same configuration were also found without the preceding ventricular pause. This strengthens the possibility that apparent AV junctional escape occurred because of markedly slow conduction through the slow AV pathway.

Novel photoactive aggregates of rhodamine 6G: dequenched and quasi-stable aggregates induced by a dewetting process.

Self-organized rhodamine 6G particles prepared by wetting/dewetting process of an ethanol solution on a hydrophilic glass surface exhibits fluorescence without quenching, showing a sharp linewidth of 2 nm with a large redshift, which indicates an existence of dye aggregates, similar to J-aggregates, inside the particle. Polarized evanescent field excitation showed that the dye molecule's transition moment along the pi-conjugation was oriented unidirectionally within particles and parallel to the substrate surface. This deduced dye orientation showed correlation between adjacent, but separated, particles and pointed roughly 45 degrees off the dewetting direction. In contrast, the particles of another pi-conjugated NK1420 dye, J-aggregates of which grows easily from an oversaturated solution, showed dye orientation along the dewetting direction preferably, still indicating the effect of self-organization, however based on a different mechanism. An annealing procedure revealed that both aggregates are in quasi-stable states, which is consistent with the rapidness of the dewetting process that may lead to crystallization in nonequilibrium.

Paroxysmal atrial fibrillation initiated by late coupled atrial extrasystoles.

A Holter recording was taken from a 62-year-old man, in whom paroxysmal atrial fibrillation was often initiated by late coupled extrasystoles rather than by close coupled ones. Coupling intervals of the extrasystoles to the preceding sinus P waves were considerably variable. When the coupling interval of an extrasystole was shorter than a critical period of 0.47 s, the extrasystole failed to be followed by another ectopic atrial deflection. On the other hand, when the coupling of an extrasystole was longer than 0.47 s, the extrasystole was followed by another atrial deflection, or it was followed by a short run of atrial tachycardia, which initiated paroxysmal atrial fibrillation. To our knowledge, such atrial fibrillation initiated by late coupled atrial extrasystoles has never been reported previously. Longitudinal dissociation in the re-entrant pathway of the extrasystoles is suggested as a possible mechanism for such initiation of paroxysmal atrial fibrillation.

Apparent disappearance of ventricular parasystole due to a marked difference between the long form and the short form of the ectopic cycles.

Electrocardiograms were taken from a 44-year-old man with irregular ventricular parasystole in whom pure parasystolic cycles without any intervening nonectopic QRS complexes were found. When a sinus impulse fell late in the parasystolic cycle, it hastened occurrence of the next parasystolic discharge. This suggested that type I second degree entrance block occurred in the re-entrant pathway containing the parasystolic focus. When a sinus impulse fell early in the parasystolic cycle, it delayed occurrence of the next parasystolic discharge. This suggested that electrotonic modulation occurred in the parasystolic focus. As a result, the difference in length between the short form and the long form of the parasystolic cycle became markedly great. When the length of two adjacent sinus cycles ranged between the short and the long parasystolic cycle, manifest parasystolic QRS complexes disappeared for a long time. In true ventricular parasystole with pure ectopic cycles, such long disappearance has never been reported before.

Accessory-pathway block on alternate beats in the Wolff-Parkinson-White syndrome: supernormal conduction as the mechanism.

The Holter monitor electrocardiograms were taken from 2 patients with intermittent Wolff-Parkinson-White syndrome. In these patients, when the heart rate was increased, accessory-pathway block on alternate beats was found and was maintained for a considerably long period. In one patient, when accessory-pathway block on alternate beats was found, a ventricular extrasystole occurred. After the long compensatory pause after that extrasystole, a sinus impulse was blocked in the accessory pathway, showing that the effective refractory period of the accessory pathway is markedly long. These findings strongly suggest that alternate sinus impulses fell in the supernormal period of the accessory pathway. An attempt was made to explain the mechanism of accessory-pathway block on alternate beats by using the concept of supernormal conduction in the accessory pathway, in the same way as in bundle-branch block on alternate beats.

Atrial escape-capture bigeminy in dominant atrial rhythm with 2:1 exit block.

A 27-year-old woman with atrial bigeminy is reported in whom long PP intervals alternate with short PP intervals. All P waves are negative in lead II and all PR intervals measure 0.12 s. In the 12-lead electrocardiogram, however, these P waves were definitely different in configuration from each other, and were divided into two groups. Namely, these negative P waves are divided into those of dominant atrial rhythm J1 with 2:1 exit block, and those of atrial escape J2. Long J1-J2 intervals alternate with short J2-J1 intervals. These electrocardiographic findings show the presence of atrial escape-capture bigeminy. Such atrial escape-capture bigeminy in dominant atrial rhythm with 2:1 exit block has never been reported before.

Apparent bradycardia-dependent right bundle branch block associated with atypical atrioventricular Wenckebach periodicity as a possible mechanism.

The Holter monitor electrocardiogram was taken from a 15-year-old male athlete. Intermittent right bundle branch block frequently occurred at rest. When sinus cycles gradually lengthened, sinus impulses were conducted to the ventricles with right bundle branch block (RBBB) in succession. When, thereafter, sinus cycles gradually shortened, sinus impulses were conducted without RBBB. However, it seems that these findings do not show true bradycardia-dependent RBBB. Atypical atrioventricular Wenckebach periodicity was occasionally found in which sudden shift from the period of comparatively short PR intervals to the period of long PR intervals occurred. In the Wenckebach periodicity, when a QRS complex occurs after a much longer pause, RBBB was not found, while when it occurs after a much shorter period, RBBB was found. This suggests that this case may be apparent bradycardia-dependent RBBB, namely, a form of tachycardia-dependent RBBB. This is the first report suggesting apparent bradycardia-dependent bundle branch block associated with gradual lengthening of sinus cycles, as a possible mechanism.

Atypical atrioventricular Wenckebach periodicity caused by conduction through triple atrioventricular junctional pathway as a probable mechanism.

Electrocardiograms were taken from an 84-year-old man with right bundle branch block in whom atypical atrioventricular Wenckebach periodicity was frequently occurred. The electrocardiographic findings as mentioned below suggested that the atypical periodicity was caused by conduction through triple atrioventricular junctional pathways as a probable mechanism. When a P wave was blocked after a markedly prolonged PR interval of 0.64 s, the RP interval containing this blocked P wave ranged between 0.84 s and 0.86 s, and the next P wave was followed by a QRS complex of the same configuration, with the PR interval of 0.35 s. On the other hand, when a P wave was blocked after a PR interval of 0.49 s or 0.52 s, the RP interval containing this blocked P wave was comparatively long, ie, 0.95 s or 0.98 s, and the next P wave was followed by a QRS complex of somewhat different configuration showing borderline left axis deviation, with a shorter PR interval of 0.21 s or 0.23 s. These findings suggest that longitudinal dissociation occurred not only in the atrioventricular junction but also in the His bundle. This is the first report suggesting triple atrioventricular junctional pathways probably associated with longitudinal dissociation in the His bundle.

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.

"Sinus node" reentrant tachycardia associated with respiration.

A 77-year-old woman (case 1) and a 57-year-old woman (case 2) with paroxysmal "sinus tachycardia" are reported in whom the tachycardia repeatedly occurred associated with respiration. In both cases, reentrant P' waves are almost the same in configuration as sinus P waves, and P'R intervals are also the same in length as PR intervals. In case 1, the tachycardia was initiated during inspiration, and was terminated during expiration; showing tachycardia-dependent initiation. On the contrary, in case 2, the tachycardia was initiated during expiration, and was terminated during inspiration; showing apparent bradycardia-dependent initiation. Although exact diagnosis was not made by electrophysiologic studies, attempts were made to explain the mechanism of such unique tachyarrhythmias associated with respiration by using the concept of sinus node reentrant tachycardia as a possible mechanism.

Apparent bradycardia-dependent advanced second-degree atrioventricular block.

A 65-year-old man with repeated chest discomfort and dizzy spells was transferred by an emergency car. On the way to hospital, his pulse was palpable as regular 4 to 5 beats followed by an unpalpable period of about 4 s. His electrocardiographic monitor showed that 4 to 5 sinus QRS complexes were followed by consecutive 3 to 4 blocked sinus P waves, which occurred repeatedly. When PP intervals gradually shortened during inspiration, sinus impulses were conducted to the ventricles, whereas when PP intervals lengthened during expiration, 3 to 4 sinus impulses were blocked in succession. An attempt was made to explain the mechanism for such apparent bradycardia-dependent atrioventricular block by using the concepts of periodic increases in vagal tone due to respiration and concealed electrotonic conduction of blocked impulses. Such a peculiar form of advanced second-degree atrioventricular block has never been reported before.