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Challenges in Clinical Electrocardiography |

Dual Ventricular Rhythm

Apurva O. Badheka, MD1; Peeyush M. Grover, MD2; Tanyanan Tanawuttiwat, MD1; Amit Badiye, MD1; George R. Marzouka, MD1; Nileshkumar J. Patel, MD3; Sandra V. Chaparro, MD1; Raul D. Mitrani, MD1
[+] Author Affiliations
1Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida
2Department of Internal Medicine, University of Miami Miller School of Medicine, Miami
3Department of Internal Medicine, Staten Island University Hospital, Staten Island, New York
JAMA Intern Med. 2013;173(13):1246-1248. doi:10.1001/jamainternmed.2013.7043a 10.1001/jamainternmed.2013.7043b.
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A 74-year-old man with a history of heart transplant presented with altered mental status. On admission, his blood pressure was 96/63 mm Hg and his heart rate was 72/min. On examination, he was in no immediate distress and had clear lung fields. There were no gallops on examination, and he had no focal neurological deficits. A median sternotomy scar and a left upper chest medical device were noted. The patient was unable to provide any history. His relatives confirmed prior heart transplant.

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Figure 1.
The 12-Lead Electrocardiogram Obtained at the Time of Initial Evaluation
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Figure 2.
The 12-Lead Electrocardiogram Obtained at the Time of Initial Evaluation (Interpretation)

A 12-lead electrocardiogram demonstrating adjacent broad and narrow QRS complexes with opposite polarity representing 2 different rhythms in the same electrocardiogram (white arrows in lead II represent transplanted heart rhythm and black arrows in lead II represent left bundle branch block morphologic rhythm of the native heart). Frequent premature ventricular contractions were observed in lead V1 (gray arrow) along the wide QRS complex rhythm (transplanted heart).

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Figure 3.
Layout of the Heterotopic Heart Transplant

A, Pictorial representation of the transplant and the respective anastomosis. B, Computed tomography of the chest (coronal view) in our patient, showing marked respective chambers and anastomosis (demonstrating the end-to-side anastomosis of the donor and recipient aorta). DAo, donor aorta; DLV, donor left ventricle; DPA, donor pulmonary artery; RAo, recipient aorta; RPA, recipient pulmonary artery; RRA recipient right atrium; RRV recipient right ventricle.

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