ACCELERATED JUNCTIONAL RHYTHM

Case: 25 year old female having a diagnosis of cyanotic congenital heart disease presented with acute lower respiratory tract infection. On examination she had central cyanosis, clubbing, kyphoscoliosis, dextrocardia, situs inversus, pulmonary stenosis, ventricular septal defect, double outlet right ventricle, right ventricular hypertrophy and transposition of great arteries.

Fig-1: ECG of a 25 year old female having dextrocardia, situs inversus and congenital cyanotic heart disease.

ECG showed tachycardia (ventricular rate 100 beats/minute), inverted p wave in all leads except aVR, V1 and V2, normal PR interval, narrow QRS complex and T wave inversion in all leads. These ECG findings are in favour of accelerated junctional rhythm.

Answer: Accelerated junctional rhythm

Discussion:

Accelerated junctional rhythm (AJR) occurs when the rate of an AV junctional pacemaker exceeds that of the sinus node. This situation arises when there is increased automaticity in the AV node coupled with decreased automaticity in the sinus node. Causes of AJR are digoxin toxicity, use of beta-agonists, e.g. isoprenaline, adrenaline, Sick sinus syndrome, myocardial ischaemia, myocarditis (acute rheumatic fever, lyme disease, Diphtheria) and metabolic states with increased adrenergic tone. Certain drugs which can cause bradycardia such as beta blockers, calcium channel blockers and antiarrhythmic agents can also induce AJR.

Junctional rhythms are classified by their rate as 1) Junctional Escape Rhythm: 40-60 bpm 2) Accelerated Junctional Rhythm: 60-100 bpm and 3) Junctional Tachycardia: > 100 bpm.

They may also be classified by aetiology as automatic Junctional Rhythms (e.g. AJR) = Due to enhanced automaticity in AV nodal cells or re-entrant Junctional Rhythms (e.g. AVNRT), due to re-entrant loop involving AV node.

Fig-2: Example of an accelerated junctional rhythm (courtesy ECG library)

ECG Features of AJR

·         Narrow complex rhythm; QRS duration < 120ms (unless pre-existing bundle branch block or rate-related aberrant conduction).

·         Ventricular rate usually 60 – 100 bpm.

·         Retrograde P waves may be present and can appear before, during or after the QRS complex.

·         Retrograde P waves are usually inverted in the inferior leads (II, III, aVF), upright in aVR + V1.

·         AV dissociation may be present with the ventricular rate usually greater than the atrial rate.

·         There may be associated ECG features of digoxin effect or digoxin toxicity.

Periods of junctional rhythm are not necessarily associated with an increase in mortality. If an obvious cause is present, such as complete heart block or sick sinus syndrome, then the morbidity or mortality is directly related to that and not to the junctional rhythm mechanism, which is serving as a "backup rhythm" during the periods of bradycardia. Accelerated junctional rhythms may be a sign of digitalis toxicity.

ECG features may be mistaken for that of dextrocardia as this patient is having dextrocardia and situs inversus. In dextrocardia inverted P wave is seen only in Lead-1 and upright P in aVR. Other features are right axis deviation, positive QRS complexes (with upright P and T waves) in aVR, inversion of all complexes (global negativity) in Lead I and absent R-wave progression in the chest leads.

Complications

Complications of junctional rhythm are usually limited to symptoms such as dizziness, dyspnea, or presyncope. Exacerbation of cardiac comorbidities, such as congestive heart failure and rate-related cardiac ischemia, may occur.

NAPCON 2019 @KOCHI

NAPCON 2019 – Kochi, Kerala

Dr C Ravindran

Organizing Chairman, Napcon 2019

“I too would like to add my thanks and congratulations. It was a great programme, lovely venue, superb entertainment, very tasty food and so nice to catch up with wonderful colleagues. I very much enjoyed the workshops I did –interested and interacting attendees and all ran perfectly”.

Mark Elliot, President, ERS

The above words reflect the general feeling of all the faculties and delegates who attended the national conference- Napcon 2019- conducted at Kochi, Kerala. It is indeed a matter of immense pride and prestige that NAPCON 2019 was hosted in a manner that was appreciated by faculty, delegates, national officials and organising team members alike. Reviews and responses from various corners have been immensely encouraging and gratifying to the organisers. We place upon record our sincere gratitude to the President, Secretary, Executive committee members of both Indian Chest Society and National College of chest physicians – India for giving us the opportunity to host the biggest academic event of the country in the field of pulmonary medicine.

I have nothing more to add, except profusely thanking all who were part of this programme organized jointly by the Kerala chapter of Indian Chest Society and Academy of Pulmonary and Critical Care Medicine.

NAPCON 2019 was organized in Hotel Grand Hyatt and Lulu Convention Centre, Kochi Bolgatty from the 21^st to 24^th of November, 2019. The workshops were held at various venues (including leading hospitals in Kochi as well as Lulu convention centre) on the 21^st of November. The inaugural ceremony was conducted from 5.30 PM to 6.30 PM on the 21^st of November. Honorable Governor of Kerala, Sri Arif Mohammed Khan officially inaugurated the conference in the presence of guest of honour,  Justice Devan Ramachandran and leaders of Indian Chest Society and National College of Chest Physicians (India). This was followed by performance of traditional art forms of Kerala.

14 workshops were conducted across various venues. The important workshop themes included pulmonary function testing, bronchoscopy, pulmonary imaging, pulmonary rehabilitation, ILD, research methodology etc. All the workshop sessions were well attended, and faculty of experience and repute guided the delegates through brief theory sessions and practical hands on training. The workshops were of immense benefit to the delegates.

The scientific sessions were conducted in 5 conference halls. A total of 350 faculties, including 25 international faculties addressed the delegates in various sessions. The scientific sessions touched upon various sub specialties in pulmonary medicine and included didactic lectures, panel discussions, pro-con debates and guideline presentations. A total of 2865 delegates registered for the conference. The sessions were well appreciated with regard to the academic content, relevance, interaction and punctuality. Time management of the conference is the one appreciated by everybody and we are proud that such a decision was well taken by faculty and delegates. Another attraction was the ambience of the venue. The Convention center was perceived as unique and majestic by the delegates with regards to its location, the mammoth space, hall arrangements, food and refreshment.

There were 830 abstracts submitted for presentation and it is a record in the history of Napcons till today. It was a herculean task to review the abstracts and to categorize for award presentation, oral presentation and poster presentations. All the abstracts were accepted and postgraduates and consultants were given the opportunity to present their work before the august audience.

NAPCON 2019 witnessed banquet on all three days and the cultural events were a blend of different art forms, both traditional and innovative, which suited the tastes of delegates hailing from different geographic territories. We had the “Keraleeyam” which summed up traditional art forms of Kerala, we had live music night by Ms Ambili Menon and we had fusion dance form “Jnanappana” by Ms Lakshmi Gopalaswamy and Mr Vineeth. Delegates were seen immersed in the cultural programmes on all three evenings.

Radiating Uniqueness

                NAPCON 2019 had a lot of unique features which serve as highlights of the conference.

1.       An awareness programme on respiratory diseases for the general public (“Healthy lung for all”) was a unique highlight. The programme took us a long way forward towards bridging the gap between pulmonologists, patients and media personnel. 500 delegates from various aspects of life attended the programme. Utilisation of local language as the mode of communications ensured deeper community level penetration.

2.       An update book on recent advanced in pulmonary medicine was released during the conference. Going through the articles, we feel that the book will definitely serve as an immediate reference guide for the postgraduates and practicing clinicians.

3.       The registration desk was made up of 5 kiosks where the registered delegate was requested to quote his unique 6 digit registration number. The process was hassle free and took on an average only 30-40 seconds

4.       Free paper sessions for consultants were arranged separately and were divided into different subcategories. This move ensured that practicing young consultants are also provided opportunity to conduct research and exhibit their work at a national forum. The sessions were well appreciated by the participants.

5.       The scientific schedule and the cultural programmes also radiated uniqueness which all the delegates appreciated across different age groups.

6.       The conference had the largest number of abstracts presented in the till date history of NAPCON.

Summary

                NAPCON 2019, when viewed through the eyes of organizers, has brought many positives to the Pulmonology fraternity of Kerala and Kochi in particular. The success of the conference is the whole hearted support and unparalleled dedication from all the pulmonologist of Kerala. This was well supplemented by the senior members of the national organizations.

                In a nutshell, hosting a successful national conference gives us lots of happiness. Almost all aspects of the conference were well appreciated and criticisms were far and few. Apt choice of the venue, formidable leadership and co-ordinated efforts of the entire Kerala state held the key to success.