Lesson V (cont)- Ventricular Arrhythmias

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2. Aberrancy vs. Ventricular Ectopy

A most important question

Aberrant Ventricular Conduction: defined as the intermittent abnormal intraventricular

conduction of a supraventricular impulse. The phenomenon comes about because of unequal
refractoriness of the bundle branches and critical prematurity of a supraventricular impulse
(see diagramof "Three Fates of PACs"). With such critical prematurity, the supraventricular
impulse encounters one bundle branch (or fascicle) which is responsive, and the other which
is refractory, and is consequently conducted with a bundle branch block or fascicular block
pattern.

ECG clues to the differential diagnosis of wide QRS premature beats:

Preceding ectopic P wave (i.e., the P' of the PAC) usually hidden in the ST-T
wave of the previous beat favors aberrant ventricular conduction. In the ECG
below note the arrow pointing at a premature P wave in the ST-T segment. The
QRS has a RBBB morphology.

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Analyze the compensatory pause: A complete pause favors ventricular ectopy

(i.e., no resetting of the sinus pacemaker; next sinus impulse comes on time). An
incomplete pause favors aberration (i.e., because supraventricular prematures
are more likely to reset the sinus node's timing). Be aware of exceptions to this
simple rule because PVCs can activate the atria retrogradely and reset the sinus
node (incomplete pause), and PACs can fail to reset the sinus node (complete
pause).

Long-Short Rule (Ashman Phenomenon): The earlier in the cycle a PAC

occurs and the longer the preceding cycle, the more likely the PAC will be
conducted with aberration (see diagram "The Three Fates of PACs"). This is
because the refractory period of the ventricular conduction system is proportional
to cycle length or heart rate; the longer the cycle length or slower the heart rate,
the longer the recovery time of the conduction system. In most individuals the
right bundle normally recovers more slowly than the left bundle, and a critically

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