The mystery of the missing P waves: a case report
Abstract Background This case highlights the diagnostic challenges of atrial flutter with concealed atrial activity on surface electrocardiograms, emphasizing the necessity of invasive electrophysiological study to avoid unnecessary pacemaker implantation in patients with structural heart disease—a...
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BMC
2025-04-01
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| Series: | Journal of Medical Case Reports |
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| Online Access: | https://doi.org/10.1186/s13256-025-05212-3 |
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| author | Yuanguo Chen Haibo Zhang Changli Han Peng Bai |
| author_facet | Yuanguo Chen Haibo Zhang Changli Han Peng Bai |
| author_sort | Yuanguo Chen |
| collection | DOAJ |
| description | Abstract Background This case highlights the diagnostic challenges of atrial flutter with concealed atrial activity on surface electrocardiograms, emphasizing the necessity of invasive electrophysiological study to avoid unnecessary pacemaker implantation in patients with structural heart disease—a scenario rarely documented in current literature. Case presentation A 60-year-old Chinese woman with rheumatic mitral stenosis and prior maze procedure presented with fatigue and bradycardia (heart rate, 47 beats per minute). Surface electrocardiograms (including modified Lewis leads) revealed no discernible P waves, while echocardiography demonstrated atrial mechanical silence. Electrophysiological study identified cavotricuspid isthmus-dependent atrial flutter with extensive right atrial low-voltage zones (voltage < 0.5 mV), explaining the absent surface atrial activity. Radiofrequency ablation achieved bidirectional isthmus block, restoring sinus rhythm (heart rate, 59 beats per minute) without pacemaker requirement. Conclusion In patients with bradycardia and electromechanical atrial dissociation, electrophysiological study proves indispensable for detecting atrial flutter obscured by severe fibrosis. This approach prevents inappropriate pacemaker implantation while restoring physiological rhythm, establishing a paradigm for managing complex arrhythmias in structural heart disease. |
| format | Article |
| id | doaj-art-7e077b67b60740aa9eb1c448bca9c0b4 |
| institution | OA Journals |
| issn | 1752-1947 |
| language | English |
| publishDate | 2025-04-01 |
| publisher | BMC |
| record_format | Article |
| series | Journal of Medical Case Reports |
| spelling | doaj-art-7e077b67b60740aa9eb1c448bca9c0b42025-08-20T02:11:46ZengBMCJournal of Medical Case Reports1752-19472025-04-011911810.1186/s13256-025-05212-3The mystery of the missing P waves: a case reportYuanguo Chen0Haibo Zhang1Changli Han2Peng Bai3Department of Cardiovascular Medicine, Ya’an People’s HospitalDepartment of Cardiovascular Medicine, Ya’an People’s HospitalDepartment of Obstetrics, Ya’an People’s HospitalDepartment of Ultrasound, Ya’an People’s HospitalAbstract Background This case highlights the diagnostic challenges of atrial flutter with concealed atrial activity on surface electrocardiograms, emphasizing the necessity of invasive electrophysiological study to avoid unnecessary pacemaker implantation in patients with structural heart disease—a scenario rarely documented in current literature. Case presentation A 60-year-old Chinese woman with rheumatic mitral stenosis and prior maze procedure presented with fatigue and bradycardia (heart rate, 47 beats per minute). Surface electrocardiograms (including modified Lewis leads) revealed no discernible P waves, while echocardiography demonstrated atrial mechanical silence. Electrophysiological study identified cavotricuspid isthmus-dependent atrial flutter with extensive right atrial low-voltage zones (voltage < 0.5 mV), explaining the absent surface atrial activity. Radiofrequency ablation achieved bidirectional isthmus block, restoring sinus rhythm (heart rate, 59 beats per minute) without pacemaker requirement. Conclusion In patients with bradycardia and electromechanical atrial dissociation, electrophysiological study proves indispensable for detecting atrial flutter obscured by severe fibrosis. This approach prevents inappropriate pacemaker implantation while restoring physiological rhythm, establishing a paradigm for managing complex arrhythmias in structural heart disease.https://doi.org/10.1186/s13256-025-05212-3Atrial flutterElectrophysiological study (EPS)Radiofrequency ablationCatheter ablationRheumatic heart diseaseCase report |
| spellingShingle | Yuanguo Chen Haibo Zhang Changli Han Peng Bai The mystery of the missing P waves: a case report Journal of Medical Case Reports Atrial flutter Electrophysiological study (EPS) Radiofrequency ablation Catheter ablation Rheumatic heart disease Case report |
| title | The mystery of the missing P waves: a case report |
| title_full | The mystery of the missing P waves: a case report |
| title_fullStr | The mystery of the missing P waves: a case report |
| title_full_unstemmed | The mystery of the missing P waves: a case report |
| title_short | The mystery of the missing P waves: a case report |
| title_sort | mystery of the missing p waves a case report |
| topic | Atrial flutter Electrophysiological study (EPS) Radiofrequency ablation Catheter ablation Rheumatic heart disease Case report |
| url | https://doi.org/10.1186/s13256-025-05212-3 |
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