Unusual Cause of Bidirectional Ventricular Rhythm

Figures

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  Figure 1. Ventricular Premature Complexes and Slow Bidirectional Ventricular Rhythm (A) Resting electrocardiogram of premature ventricular complexes in the form of ventricular bigeminy. (B) 24-h Holter monitor traces demonstrating a run of nonsustained slow ventricular rhythm with right bundle branch block morphology in V1 but alternating left and right frontal axis. (C) ECG in sinus rhythm with sinus arrhythmia, a QTc complex of 0.39 s, and a large U-wave in the precordial lead with a QTU interval of 0.51 s.

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  Figure 2. Echocardiographic and CMR Images of the Proband Heart (A) Apical 4-chamber view of 2-dimensional echocardiogram showing normal wall thickness and chamber dimensions. (B) CMR image of 4-chamber phase sensitive inversion recovery view demonstrating a linear myocardial crypt (arrow) seen on 3D balanced turbo field-echo sequence images enhancing post-contrast on delayed images. There was no evidence of ventricular septal defect or ventricular hypertrophy. CMR = cardiac magnetic resonance.

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  Figure 3. Histological Changes on Endomyocardial Septal Biopsy Samples of the Proband Heart (A) Endomyocardial biopsy fragment (arrows) showed mild hypertrophy with nucleomegaly, myocyte disarray (hematoxylin and eosin [H&E] stain; original magnification ×10]). (B) Intermyofiber fibrosis (blue arrow) (Masson trichrome [MT] stain; original magnification ×40). Inflammatory cell infiltrate was absent.