What Is the Structural Abnormality in This Patient?

Abstract

A 59-year-old man presented to our hospital reporting 3 months of exertional dyspnea, ortopnea, paroxysmal nocturnal dyspnea, and lower leg edema. On physical examination, he had jugular venous distention, bibasilar rales, large tender liver, and peripheral edema. On cardiac auscultation, he had a regular heart rate with premature ventricular contractions, systolic ejection grade III/VI cardiac murmur in pulmonic area, and louder P2 than A2. Chest x-ray showed cardiac enlargement, and an ECG (Figure 1) was recorded; because of premature heartbeats on admission, a 24-hour Holter ECG was obtained (Figure 2). On the basis of ECG findings, what is the rhythm of the patient and what is the structural abnormality? Figure 1. ECG obtained during emergency department admission. Figure 2. Twenty-four–hour Holter ECG showing 1 premature ventricular contraction. Please turn the page to read the diagnosis. To interpret the ECG and determine the anatomic abnormality in this case, it is necessary to take into account the clinical and ECG findings in combination, which are remarkable for right ventricle (RV) failure as demonstrated by the findings on physical examination of jugular venous distention, large tender liver, and peripheral lower leg edema. In addition, there is a systolic murmur, fixed splitting of S2 and louder P2, thus suggesting an interatrial septal defect. The ECG shows a sinus rhythm with an extremely tall P wave in inferior and precordial leads and notable increased duration and depth of terminal-negative portion of P wave in …