medical term wandering atrial pacemaker

Ectopic Supraventricular Arrhythmias

Various rhythms result from supraventricular foci (usually in the atria). Diagnosis is by electrocardiography. Many are asymptomatic and require no treatment.

(See also Overview of Arrhythmias .)

Ectopic supraventricular rhythms include

Atrial premature beats

Atrial tachycardia, multifocal atrial tachycardia, nonparoxysmal junctional tachycardia, wandering atrial pacemaker.

Atrial premature beats (APB), or premature atrial contractions (PAC), are common episodic impulses. They may occur in normal hearts with or without precipitating factors (eg, coffee, tea, alcohol, pseudoephedrine ) or may be a sign of a cardiopulmonary disorder. They are common in patients with chronic obstructive pulmonary disease (COPD). They occasionally cause palpitations.

Diagnosis is by electrocardiography (ECG—see figure Atrial premature beat ).

Atrial premature beat (APB)

Image courtesy of L. Brent Mitchell, MD.

APBs may be normally, aberrantly, or not conducted and are usually followed by a noncompensatory pause. Aberrantly conducted APBs (usually with right bundle branch block morphology) must be distinguished from premature beats of ventricular origin.

Atrial escape beats are ectopic atrial beats that emerge after long sinus pauses or sinus arrest. They may be single or multiple; escape beats from a single focus may produce a continuous rhythm (called ectopic atrial rhythm). Heart rate is typically slower, P wave morphology is typically different, and PR interval is slightly shorter than in sinus rhythm.

Atrial tachycardia is a regular rhythm caused by the consistent, rapid atrial activation from a single atrial focus. Heart rate is usually 150 to 200 beats/minute; however, with a very rapid atrial rate, nodal dysfunction, and/or digitalis toxicity, atrioventricular (AV) block may be present, and ventricular rate may be slower. Mechanisms include enhanced atrial automaticity and intra-atrial reentry.

Atrial tachycardia is the least common form (5%) of paroxysmal supraventricular tachycardia and usually occurs in patients with a structural heart disorder. Other causes include atrial irritation (eg, pericarditis

Symptoms are those of other tachycardias (eg, light-headedness, dizziness, palpitations, and rarely syncope).

Diagnosis is by electrocardiography (ECG); P waves, which differ in morphology from normal sinus P waves, precede QRS complexes but may be hidden within the preceding T wave (see figure True atrial tachycardia ).

True atrial tachycardia

Vagal maneuvers may be used to slow the heart rate, allowing visualization of P waves when they are hidden, but these maneuvers do not usually terminate the arrhythmia (demonstrating that the AV node is not an obligate part of the arrhythmia circuit).

Treatment involves managing causes and slowing ventricular response rate using a beta-blocker or calcium channel blocker. An episode may be terminated by direct current cardioversion . Pharmacologic approaches to termination and prevention of atrial tachycardia include antiarrhythmic drugs in class Ia, Ic, or III. If these noninvasive measures are ineffective, alternatives include overdrive pacing and ablation .

Multifocal atrial tachycardia (chaotic atrial tachycardia) is an irregularly irregular rhythm caused by the random discharge of multiple ectopic atrial foci. By definition, heart rate is > 100 beats/minute. On ECG, P-wave morphology differs from beat to beat, and there are ≥ 3 distinct P-wave morphologies. The presence of P waves distinguishes multifocal atrial tachycardia from atrial fibrillation . Except for the rate, features are the same as those of wandering atrial pacemaker. Symptoms, when they occur, are those of rapid tachycardia. Multifocal atrial tachycardia can be due to an underlying pulmonary disorder such as chronic obstructive pulmonary disease coronary artery disease , and electrolyte abnormalities such as hypokalemia . Treatment is directed at the underlying disorder.

Nonparoxysmal junctional tachycardia is caused by abnormal automaticity in the AV node or adjacent tissue, which typically follows open heart surgery, acute inferior myocardial infarction, myocarditis, or digitalis toxicity. Heart rate is 60 to 120 beats/minute; thus, symptoms are usually absent. ECG shows regular, normal-appearing QRS complexes without identifiable P waves or with retrograde P waves (inverted in the inferior leads) that occur shortly before ( < 0.1 second) or after the QRS complex. The rhythm is distinguished from paroxysmal supraventricular tachycardia by the lower heart rate and gradual onset and offset. Treatment is directed at causes.

Wandering atrial pacemaker (multifocal atrial rhythm) is an irregularly irregular rhythm caused by the random discharge of multiple ectopic atrial foci. By definition, heart rate is ≤ 100 beats/minute. Except for the rate, features are the same as those of multifocal atrial tachycardia. Treatment is directed at causes.

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INTRODUCTION

This topic will review the definition, pathogenesis, etiology, and treatment of MAT in adults. Other tachycardias of atrial origin, as well as the discussion of this arrhythmia in children, are reviewed separately. (See "Focal atrial tachycardia" and "Atrial tachyarrhythmias in children" and "Atrioventricular nodal reentrant tachycardia" and "Atrioventricular reentrant tachycardia (AVRT) associated with an accessory pathway" and "Atrial fibrillation: Overview and management of new-onset atrial fibrillation" .)

DEFINITION, PATHOGENESIS, AND PREVALENCE

Terminology  —  A number of authors have used the term "chaotic" to describe MAT [ 3-5 ]. However, chaos in modern usage in nonlinear dynamics and mathematics implies there is order in what appear to be random events [ 6 ]. A more accurate term for this arrhythmia is probably "multiform" as there is no proof that the arrhythmia is actually multifocal, although multifocal remains the commonly used term [ 1 ].

The tachycardic threshold for multifocal atrial tachycardia (MAT) has traditionally been set at 100 bpm, but a review of 60 patients with multifocal atrial arrhythmias found a stronger association between the incidence of COPD exacerbations and the diagnosis of MAT if a threshold of 90 bpm was used [ 7 ]. The definition of MAT also requires the presence of at least three distinct P-wave morphologies.

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• Wandering atrial pacemaker
• 2 Clinical Features
• 3.1 Palpitations
• 4.2 Diagnosis
• 5 Management
• 6 Disposition
• 8 External Links
• 9 References
• Three or more ectopic foci within the atrial myocardium serve as the pacemaker
• Rate is less than 100bpm (in contrast to MAT )
• Is irregularly irregular therefore sometimes confused with atrial fibrillation and sinus arrhythmia
• Intrinsic cardiac or pulmonary disease
• Metabolic derangements
• Drug toxicity (including Digoxin )

Clinical Features

• Often seen in the extremes of age and in athletes
• Rarely causes symptoms

Differential Diagnosis

Palpitations.

• Narrow-complex tachycardias
• Wide-complex tachycardias
• Second Degree AV Block Type I (Wenckeback)
• Second Degree AV Block Type II
• Third Degree AV Block
• Premature atrial contraction
• Premature junctional contraction
• Premature ventricular contraction
• Sick sinus syndrome
• Acute coronary syndrome
• Cardiomyopathy
• Congenital heart disease
• Congestive heart failure (CHF)
• Mitral valve prolapse
• Pacemaker complication
• Pericarditis
• Myocarditis
• Valvular disease
• Panic attack
• Somatic Symptom Disorder
• Drugs of abuse (e.g. cocaine )
• Medications (e.g. digoxin , theophylline )
• Thyroid storm
• Pulmonary embolism
• Dehydration
• Pheochromocytoma

• ECG should show three distinct P wave morphologies with a ventricular rate <100bpm
• Rarely requires treatment

Disposition

• Outpatient management
• Multifocal atrial tachycardia
• Dysrhythmia

External Links

• Richard Cunningham
• fardis tavangary
• Ross Donaldson
• Privacy policy
• Disclaimers

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Day 6:  Ectopic Arrhythmias and Triggered Activity

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Day 6: ectopic arrhythmias and triggered activity.

• Interpretations of Sample Tracings
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Ectopy—a disorder of impulse formation

Mechanisms of ectopic arrhythmias

Ectopic arrhythmias require:

Default—slowing of the normal dominant sinus pacemaker which allows a slower focus to take control, or

Usurpation—an acceleration of a lower pacemaker which takes control by virtue of being faster than the sinus rate

Disorders of the sinus node, such as SA arrest, SA exit block, or excessive vagal tone may allow a lower focus to take control by default

A variety of factors, including digitalis toxicity, hypoxia, electrolyte disturbances, ischemia, or chronic lung disease may stimulate an ectopic focus to accelerate and usurp control from the SA node

Properties of ectopic arrhythmias

Ectopic arrhythmias usually start and stop gradually ( non-paroxysmally )

They are not usually initiated by a premature beat

They may be somewhat irregular

They are not terminated by vagal maneuvers, although AV block may be increased

AV block of varying degrees is frequently present (particularly if digitalis toxicity is the cause)

These arrhythmias are usually quite resistant to treatment with standard class I or III agents

Catheter ablation may be effective if a causative agent cannot be identified or treated

The major ectopic arrhythmias

Wandering atrial pacemaker

Mechanisms and causes

There are three or more ectopic atrial pacemakers

This arrhythmia is typically seen in young healthy persons, particularly athletes

The etiology is uncertain

Heart rate—the heart rate is 60–100 and is usually irregular

ECG morphology ( Day 6-01 )

There are at least three P wave morphologies with varying PR intervals

There is usually moderate variation in the heart rate

Multifocal atrial tachycardia

Caused by multiple ectopic atrial foci

Chronic lung disease is typically the underlying clinical abnormality, although it can also occur in the setting of hypoxia, electrolyte abnormalities, acid-base disturbances, and ischemia (i.e., frequently in the intensive care setting)

ECG morphology ( Day 6-02 )

The rate is 100–140

There is typically 1:1 AV conduction

This arrhythmia is frequently confused with atrial fibrillation; the distinction is an important one since management is usually very different

Ectopic atrial rhythms

A single ectopic atrial focus accelerates and usurps control from the sinus node, or the sinus node slows down and allows an ectopic focus to appear

Digitalis toxicity, electrolyte abnormalities, ischemia, hypoxia, and chronic lung disease are typical causes

ECG morphology ( Day 6-03 ) ( Day 6-04 )

The P waves are of the same morphology but have an abnormal axis, indicating their ectopic origin

The atrial rate may be slightly irregular

AV block of varying degrees is sometimes present (particularly if digitalis toxicity is the cause)

Atrial tachycardia with AV block should be considered a manifestation of digitalis toxicity until proven otherwise ( Day 6-05 )

The atrial rate in atrial tachycardia is usually 140–200

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Wandering Atrial Pacemaker EKG Interpretation with Rhythm Strip

Ekg features, wandering atrial pacemaker ekg interpretation example.

This website is only for professional medical education. Contact your doctor for medical care. 2024 © MedEdu LLC. All Rights Reserved. Terms & Conditions | About Us | Privacy | Email Us

Wandering Atrial Pacemaker ECG Interpretation #312

Description.

• Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring.
• Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering.
• These changes in the locus of stimulation affect the morphology of the P waves.
• In Wandering Atrial Pacemaker ECG, you must observe at least three different shaped P waves. No other changes in the tracing may be observed. The rhythm may or may not be regular.
• The PR interval is often affected, but does not have to be.
• The bottom line, is you must observe at least three different shaped P waves.

Practice Strip

Analyze this tracing using the five steps of rhythm analysis.

• Rhythm: Irregular
• P wave: Changing Shapes (3 or more)
• PR interval: Variable
• Interpretation: Wandering Atrial Pacemaker

Authors and Reviewers

• ECG heart rhythm modules: Thomas O'Brien.
• ECG monitor simulation developer: Steve Collmann
• 12 Lead Course: Dr. Michael Mazzini, MD .
• Spanish language ECG: Breena R. Taira, MD, MPH
• Medical review: Dr. Jonathan Keroes, MD
• Medical review: Dr. Pedro Azevedo, MD, Cardiology
• Last Update: 11/8/2021
• Electrocardiography for Healthcare Professionals, 6th Edition Kathryn Booth and Thomas O'Brien ISBN10: 1265013470, ISBN13: 9781265013479 McGraw Hill, 2023
• Rapid Interpretation of EKG's, Sixth Edition Dale Dublin Cover Publishing Company
• EKG Reference Guide EKG.Academy
• 12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs Aaron Reed Create Space Independent Publishing
• Heart Sounds and Murmurs: A Practical Guide with Audio CD-ROM 3rd Edition Elsevier-Health Sciences Division Barbara A. Erickson, PhD, RN, CCRN
• The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds, Murmurs, EKG Jonathan Keroes, David Lieberman Publisher: Lippincott Williams & Wilkin) ISBN-10: 0781784425; ISBN-13: 978-0781784429
• Project Semilla, UCLA Emergency Medicine, EKG Training Breena R. Taira, MD, MPH
• ECG Reference Guide PracticalClinicalSkills.com

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wandering pacemaker

Medical Definition of wandering pacemaker

Dictionary entries near wandering pacemaker.

wandering cell

Wangensteen apparatus

Cite this Entry

“Wandering pacemaker.” Merriam-Webster.com Medical Dictionary , Merriam-Webster, https://www.merriam-webster.com/medical/wandering%20pacemaker. Accessed 29 Apr. 2024.

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• JACC Case Rep
• v.2(7); 2020 Jun 17

Wandering Atrial Pacemaker Wire

Jennifer d. hua.

a Philadelphia College of Osteopathic Medicine Georgia, Suwanee, Georgia

Shoheb S. Ali

b Internal Medicine Residency Program, Northside Hospital Gwinnett, Lawrenceville, Georgia

Vamsi Reddy

c Medical College of Georgia, Augusta University, Augusta, Georgia

Salil J. Patel

d Cardiovascular Group P.C., Lawrenceville, Georgia

Temporary epicardial pacing, routinely used after cardiac surgery, employs wires anchored to the epicardium allowing removal via traction. In cases of resistance, the temporary wires are cut flush at the skin. We present a rare noninfectious case of a migrated retained temporary pacing wire into the left heart. ( Level of Difficulty: Beginner. )

Graphical abstract

Temporary epicardial pacing, routinely used after cardiac surgery, employs wires anchored to the epicardium allowing removal via traction. In cases of…

An asymptomatic 65-year-old man, with a history of minimally invasive aortic valve replacement 2 years prior, presented for an outpatient transesophageal echocardiogram (TEE). The TEE revealed a linear density beginning in the left ventricle (LV) adjacent to the anterior leaflet of the mitral valve ( Figure 1A ) before crossing through the bioprosthetic aortic valve and finally terminating in the ascending aorta proximal to the brachiocephalic artery. Computed tomography angiography confirmed a thin linear metallic foreign body measuring up to 15 cm ( Figure 1B ). On subsequent fluoroscopy, the object appeared to be fixed in the LV, free-floating at the level of the aortic valve as well as within the ascending aorta ( Figure 1C ).

Imaging of the Migrated Temporary Epicardial Pacemaker Wire

(A) Transesophageal echocardiogram revealing a linear density (W) in the left ventricle (LV) attached to the mitral valve (MV) traveling through the bioprosthetic aortic valve (AV) and into the ascending aorta (A). (B) Computed tomography angiogram showing the 15-cm density (W) in the LV coursing through the bioprosthetic AV with redundancy in the aorta (A). (C) Fluoroscopy showing migrated temporary pacing wire (W) running through the bioprosthetic AV as well as other retained epicardial pacing wires (arrows) . (D) Retrieved temporary epicardial pacing wire. LA = left atrium; RV = right ventricle.

Employing the aforementioned noninvasive imaging modalities, we formulated a plan to retrieve the foreign body. The TEE first revealed the linear density, and computed tomography angiography ruled out aortic dissection and offered further insight into its position. Additionally, use of fluoroscopy allowed us to evaluate its movement and determined the distal end was unattached. Interventional radiology was consulted to attempt percutaneous snare removal of the object with cardiac surgery on standby. Successful retrieval of the foreign body revealed a migrated temporary epicardial pacing wire ( Figure 1D ). After tolerating the procedure, the patient had stable mitral valve function and was subsequently discharged.

During the aortic valve replacement procedure 2 years prior, bipolar pacing wires were placed on the ventricle while 2 atrial wires were attached to the atrial epicardium and tunneled through the skin. Temporary epicardial pacing, routinely used after cardiac surgery, employs wires lightly anchored to the epicardium which allows for removal via gentle traction through the skin. In cases of resistance, the temporary wires are cut flush at the skin ( 1 ). The migration of retained temporary epicardial pacing wires is very rare but has been suspected to be due to direct perforation of the cardiac musculature or neighboring vascular structures. Most reported cases occurred within the context of an infection—a possible source of tissue weakening and disruption leading to direct perforation ( 2 ).

The mechanism of this wire’s migration from its original attachment at the epicardium of the right atrium into the LV is still anatomically unclear, as it was found entirely within the left heart and aorta under noninfectious conditions. It was fortuitously affixed to a chord of the mitral valve apparatus, preventing further travel into the aorta. Among previously reported cases, the few wires that had migrated into the left heart were all found within the aorta or carotid arteries—none had been found within the LV. Only 1 other case ( 2 ) describes left-sided migration under noninfectious conditions. Previous cases hypothesized that the wires may have perforated through the aortic wall ( 3 ). In our patient, the chance event of the wire fortuitously attaching to the mitral valve apparatus and its predominantly LV location rule out aortic perforation. The treatment options are percutaneous endovascular retrieval or surgical repair, with endovascular intervention being the preferred, less invasive option ( 3 ).

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page .