Ventricular Fibrillation (VF) • LITFL • ECG Library Diagnosis

Ventricular fibrillation (VF) is the most important shockable cardiac arrest rhythm. It is invariably fatal unless advanced life support is rapidly instituted.

ECG findings in Ventricular Fibrillation (VF)

• Chaotic irregular deflections of varying amplitude
• No identifiable P waves, QRS complexes, or T waves
• Rate 150 to 500 per minute
• Amplitude decreases with duration (coarse VF –> fine VF)

Ventricular fibrillation (rhythm strip): Chaotic irregular deflections without identifiable P-QRS-T waves

Clinical significance of VF

Ventricular fibrillation (VF) is the most important shockable cardiac arrest rhythm.

• The ventricles suddenly attempt to contract at rates of up to 500 bpm
• This rapid and irregular electrical activity renders the ventricles unable to contract in a synchronised manner, resulting in immediate loss of cardiac output
• The heart is no longer an effective pump and is reduced to a quivering mess
• Unless advanced life support is rapidly instituted, this rhythm is invariably fatal
• Prolonged ventricular fibrillation results in decreasing waveform amplitude, from initial coarse VF to fine VF, ultimately degenerating into asystole due to progressive depletion of myocardial energy stores

Mechanism

In the presence of ischaemic heart disease VF may be preceded by:

• Premature ventricular contractions (PVCs)
• ST changes
• R on T phenomenon
• Sinus pause
• QT prolongation
• Ventricular tachycardia
• Supraventricular arrhythmias
• Sinus tachycardia

The underlying mechanism of VF is not fully understood. Several mechanisms have been hypothesised:

• Multiple wavelet mechanism: Multiple small wandering wavelets are formed, and the fibrillation is maintained by re-entry circuits formed by some of these wavelets
• Mother rotor mechanism: A stable re-entry circuit is formed, the ‘mother rotor’. The ‘mother rotor’ then gives rise to propagating unstable ‘daughter’ wavefronts, which results in the chaotic electrical activity seen on the ECG. Animal models suggest in any instance of VF there may be one or multiple ‘mother rotors’

Causes of Ventricular Fibrillation (VF)

Cardiac

• Myocardial ischemia / infarction
• Cardiomyopathy (dilated, hypertrophic, restrictive)
• Channelopathies e.g. Long QT (acquired / congenital) causing TdP –> VF and Brugada syndrome
• Aortic stenosis
• Aortic dissection
• Myocarditis
• Cardiac tamponade
• Blunt trauma (Commotio Cordis)

Respiratory

• Tension pneumothorax
• Pulmonary embolism
• Primary pulmonary hypertension
• Sleep apnoea
• Bronchospasm
• Aspiration

Toxic and Metabolic

• Drugs (e. g. verapamil in patients with AF+WPW)
• Drug-induced QT prolongation with torsades de pointes

Environmental

• Electrical shocks, drowning, hypothermia
• Sepsis

Neurological

• Seizure
• CVA

ECG Examples of VF

Example 1

• Typical rhythm strip of VF

Example 2

• Appearance of fine VF

Example 3

• VF should never be diagnosed from the 12-lead ECG!

Example 4

• “R on T” phenomenon causing Torsades de Pointes, which subsequently degenerates to VF
• Notice that in this case the rhythm strip was recorded after the standard 12 leads — most ECG machines record them simultaneously

Example 5

• R on T leads to polymorphic VT, which then degenerates to VF
• The inferior ST elevation in the first part of the ECG may represent either inferior STEMI or simply the effects of ventricular pacing. Note the small pacing spikes in front of each QRS complex
• The magnitude of ST elevation suggests that this is an inferior STEMI in a paced patient (see Sgarbossa’s criteria)
• Again, the rhythm strip is recorded after the standard 12 leads.

and another example…

Example 6

• This patient is shocked out of VF five times in ten minutes!
• The subsequent rhythm in each case appears to be an accelerated idioventricular rhythm (broad QRS with AV dissociation), possibly with some fusion complexes in the second and third rhythm strips

• Torsades de Pointes
• Ventricular tachycardia
• Le Syndrome de Haïssaguerre (idiopathic VF)

References

• Da Costa D, Brady WJ, Edhouse J. Bradycardias and atrioventricular conduction block. BMJ. 2002 Mar 2;324(7336):535-8
• Ideker RE, Rogers JM. Human ventricular fibrillation: wandering wavelets, mother rotors, or both? Circulation. 2006 Aug 8;114(6):530-2.
• Nash MP, Mourad A, Clayton RH, Sutton PM, Bradley CP, Hayward M, Paterson DJ, Taggart P. Evidence for multiple mechanisms in human ventricular fibrillation. Circulation. 2006 Aug 8;114(6):536-42
• ten Tusscher KH, Mourad A, Nash MP, Clayton RH, Bradley CP, Paterson DJ, Hren R, Hayward M, Panfilov AV, Taggart P. Organization of ventricular fibrillation in the human heart: experiments and models. Exp Physiol. 2009 May;94(5):553-62.

Advanced Reading

Online

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.

Textbooks

• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Hampton J. The ECG Made Practical 7e, 2019
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
• Smith SW. The ECG in Acute MI. 2002 [PDF]

LITFL Further Reading

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest

Cite this article as: Ed Burns and Robert Buttner, “Ventricular Fibrillation (VF),” In: LITFL – Life in the FastLane, Accessed on June 14, 2023, https://litfl. com/ventricular-fibrillation-vf-ecg-library/.

Ed Burns

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

Robert Buttner

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

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15 most expensive pocket and wrist watches in the world

A watch is a timeless classic accessory, which is not only a device for determining the exact time, but also an important component of the image of a modern person. Some of them are real works of art, striking not only with their beauty, but also with the complexity of the mechanism, which, of course, is reflected in their price. We present to your attention the 15 most expensive pocket and wrist watches in the world, the cost of which exceeds $ 2 million.

15th place
The Parmigiani Fleurier Fibonacci is a white gold pocket watch with lotus flower inlay that mimics the Fibonacci golden ratio. The flower is studded with diamonds, rubies, emeralds, sapphires and semi-precious stones with a total weight of 49.5 carats. The watch is equipped with a perpetual calendar, minute repeater and moon phase indicator. Made by Parmigiani Fleurier Fibonacci exclusively to order. The luxury accessory will cost $2.4 million and the manufacturing process will last about 2 years.

14th place
The Franck Muller Aeternitas Mega 4 is the most complex mechanical wristwatch in the world, valued at $2.7 million. This creation of watchmaking art in a white gold case consists of 1483 parts. They are equipped with 36 functions, 25 of which are presented on the dial, dotted with nineteen hands. The Aeternitas Mega 4 features three time zones, a 999-day Gregorian calendar, a flyback chronograph and Westminster Battle. You can buy unique watches only in New York and Geneva.

13th place
Cartier Secret Watch with Phoenix is ​​a rhodium shaped phoenix wristwatch plated with 18x white gold. The body of the mythical bird is encrusted with 3010 diamonds with a total weight of 80.13 carats. The eyes of the phoenix are pear-shaped emeralds and diamonds of 3.53 carats. The cost of this work of art is 2,755,000 conventional units.

12th place
The unique wrist watch of the famous Swiss company Patek Philippe, made in the distant 1942 year. Made of 18 carat gold, the accessory is equipped with a moon phase indicator and a perpetual calendar. Patek Philippe (1942) sold in November 2009 at Christie’s in Geneva for $2,773,721.

11th place
Patek Philippe Model 2523 Heures Universelles (1953) is another creation of the famous watch manufacturer, sold in May 2012 at Christie’s Geneva auction for $2,990,154. This gold wrist watch with a complicated design shows the time in 24 time zones. The dial of the model is decorated with an enamel map of North America.

10th place
Piaget Emperador Temple is a wrist watch that is a real triumph of luxury and brilliance. The accessory, made of 18 carat gold and encrusted with a huge number of diamonds, was created in 2010. The top of the watch is adorned with 481 round diamonds and 207 baguettes. The dial is studded with 11 baguette-cut diamonds and 162 round-cut diamonds, while the bracelet holds 350 baguettes. In total, two copies of the Piaget Emperador Temple were produced, but one of them has already been sold. The cost of the watch is 3.3 million dollars.

9th place
The Patek Philippe Single-Button Chronograph Watch (1928) is a single-button cushion-shaped chronograph created in 1928 for an anonymous buyer. They are made of 18 carat white gold and set with 28 precious stones. The watch was sold in May 2011 at Christie’s, and the price paid for it was $3,637,408.

8th place
JB Champion’s platinum observatory chronometer – 19 platinum wrist watch52 years old, made by Patek Philippe for the legendary American collector J. B. Champion. In November 2012, they were sold at Christie’s in Geneva for $3,992,858. This is the world’s most expensive watch without complicated features.

7th place
Patek Philippe Platinum World Time (1939) – retro wrist watch of the great Swiss company, created by the outstanding Genevan watchmaker Louis Cottier in 1939 year. It is equipped with a self-winding movement that allows you to know the time in any of the world’s time zones, while the watches are distinguished by a reliable mechanism and an elegant design. Patek Philippe Platinum World Time were sold at the Geneva Antiquorum auction in 2002 for 4,026,524 conventional units.

6th place
Paris Precision Stopwatch by Breguet & Fils. – an exquisite pocket watch with a stopwatch, made of 18 carat gold and platinum and decorated with precious stones. They represent the first experimental chronometer from Breguet, equipped with two dials with Roman and Arabic numerals. The first watch was purchased by Mr. Garcia in August 1814 at an auction in London for 5,000 francs. The last price paid for them in May 2012 at Christie’s was 4,682,165 conventional units.

5th place
The Patek Philippe Caliber 89 is a pocket watch with two dials, created in 1989 to celebrate the 150th anniversary of the famous Swiss company. They became the most complicated watch ever produced by Patek Philippe. In total, four copies were produced, each of which was made of precious metal: yellow gold, rose gold, white gold and platinum. A luxurious accessory that took watchmakers as much as 9years of work, decorated with 126 precious stones, consists of 1728 parts and has 33 functions. The unique watch weighs 1.1 kg. Key features of the Caliber 89 include a calendar, moon phase indicator, chronograph, thermometer, chime and star map. The cost of unique watches is 5 million dollars.

4th place
The Patek Philippe Reference 1527 is a classic 1943 wristwatch crafted in gold with 23 gems. Originally owned by the Stern family, which owns the Patek Philippe brand. The watch is equipped with a perpetual calendar and a moon phase indicator. At a Christie’s auction in May 2010, a Patek Philippe Reference 1527 was purchased for 5.63 million conventional units.

3rd place
The Patek Philippe Henry Graves Supercomplication is a super-exclusive watch that was born in 1932 as a result of a dispute between two wealthy American friends. They bet who among them will be the owner of the most complicated watch in the world. The winner was New York banker Henry Graves, who commissioned a watch from Patek Philippe. It took 5 years to complete this incredibly complex order. Watch made of 18K gold and composed of 900 parts, equipped with 24 functions. An interesting feature of the Patek Philippe Henry Graves Supercomplication is the starry sky on the dial, which looks exactly the same as from the window of Graves’ house in New York. In 1999, at Sotheby’s, they were purchased by an anonymous buyer for $11,002,500 and are now in the watch museum in Geneva, Switzerland.

2nd place
201-carat Chopard is an exclusive bracelet watch that combines the achievements of jewelry and watchmaking. Chopard released them in 2008. The watch is generously studded with a mountain of diamonds, among which you can see a small dial. Three main heart-shaped diamonds – white, red and blue – are located around the dial. Their total weight is 38 carats, while the weight of all gemstones, the number of which reaches 874, is 200 carats. This piece of art is valued at $25 million.

1st place
The winner of the rating is the watch of the Swiss brand Jaeger LeCoultre – Joaillene Manchette, the approximate cost of which is 26 million dollars.