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Electro-Mechanical Dissociation in A-V Block

On physical examination, the pulse was regular with a rate of 36/min.; the blood pressure was 230/100. The jugular veins were somewhat engorged and showed moderate pulsations interrupted by large cannon waves. There was no cyanosis and no orthopnea. The heart was enlarged as the apical impulse was palpable in the 6th left i.c.s. at the anterior axillary line. On auscultation, the first sound was of variable intensity. The second sound was normally split. There were low pitched atrial sounds, best heard in the fourth and fifth left i.c.s. near the sternal edge. A soft, blowing, grade 2/6 pansystolic murmur was audible from the 4th to the 6th i.c.s. It changed tonality and became somewhat harsher at the base. The lungs were clear. There was no enlargement of the liver and no pitting edema. X-ray. A chest film showed marked enlargement of the heart and moderate enlargement of the aorta. Electrocardiogram. On the first admission, there was sinus rhythm, right bundle branch block, and possible evidence of a small, old inferior infarct. In subsequent tracings, a grade 2 A-V block appeared with a 2:1 A-V ratio (Fig. 1); however, this block subsequently disappeared. On the second admission, a complete A-V block was noted, and the ventricular rate was 32/min. (Fig. 2). Following implantation of an artificial demand pacemaker, the ventricular rate became 72/min. (Fig. 3). Phonocardiograrrz. The data of auscultation were confirmed. (1) During the period of grade 2 A-V block, there was a varying amplitude of the first sound. Diastolic sounds were present in coincidence with the atrial