EXTRA COPY — ECG Blog #531: Wide Tachycardia — EXTRA COPY

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Figure-1: The initial ECG in today's case — obtained from XXXX (To improve visualization — I've digitized the original ECG using PMcardio).

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Figure-2: XXXX

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Acknowledgment: My appreciation to @PrecordialSwirl for submission of today's case with these tracings.

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Arman Bajwa armanbajwa194@gmail.com ME to email Arman whenever this is published !!!

I should say, “My appreciation to — @PrecordialSwirl — for sending me this tracing and this case”

You can keep my real name anonymous but tag my twitter account @PrecordialSwirl, thats where i post all of the same ecgs that I send to you.

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Arman Bajwa — Nurse in Australia

Arman Bajwa armanbajwa194@gmail.com ME to email Arman whenever this is published !!!

I should say, “My appreciation to — @PrecordialSwirl — for sending me this tracing and this case”

You can keep my real name anonymous but tag my twitter account @PrecordialSwirl, thats where i post all of the same ecgs that I send to you.

 

THE CASE:

Hi dr. Grauer — Thanks for replying to my email about the QT interval. This time I have an ECG challenge for you. Pt was early 60s. Developed sudden tachycardia, asymptomattic, no prior history of MI or IHD.

I’d like to know how you would approach this. Then I’ll tell you how we reverted this and what the EP study showed.

Thanks and Kind regards

Arman

MY REPLY:

Hi Arman. Regular WCT (Wide-Complex Tachycardia) at ~170/minute without sinus P waves.

• PINK arrows look like 1:1 VA conduction.
• QRS morphology is perfectly consistent with LBBB conduction (upright R waves in I,aVL,V6 — and very steep initial downslope in the anterior leads).
• So clearly could be a reentry SVT rhythm. If completely stable and presented to an ED — Could try Adenosine as a diagnostic/therapeutic trail (should cardiovert the patient if this is AVNRT or AVRT). For any concerns, or if at any time the patient became unstable — then cardiovert.
• Note: 1:1 VA conduction can occur with both reentry SVTs as well as with VT — so this finding does not help in diagnosis.
• Cannot rule out VT on this single ECG — but morphology suggests SVT more likely.

 

Arman — I’d LOVE to use this case as an ECG Blog! (Readers always love the WCT cases!  — especially when you will be giving me follow-up and EP input! )

• I’d be happy to acknowledge you and/or any of your colleagues (Please tell me the city and country where you are from — OR, the case could be anonymous if you prefer). It may be a little while — as I have other cases to go before this one.
• P.S. — I’m curious — What is your medical specialty? — :)

ARMAN REPLY:

Thanks for your quick response. I’m a new RN working in a cardiology ward in Australia. I just graduated nursing school 3 months ago. Yes I’m happy for you to use the ecg on your blog. You can keep my real name anonymous but tag my twitter account @PrecordialSwirl, thats where i post all of the same ecgs that I send to you.

 

More background- the pt had an SVT ablation 5 years ago but developed palpitations again. Was evaluated outpatient and admitted for an elective ablation. Baseline ECG had no aberrancy. He developed this tachycardia in our ward, a day before his scheduled ablation. Good thing about a telemetry unit is that we could go back in time and see that it initiated with a PAC( I curse myself for not saving that strip). The tachycardia was terminated with 6 of adenosine.

 

EP results- concealed left lateral accessory pathway with no inducible tachycardia. Slow- Fast AVNRT induced and ablated. Rate related LBBB. 

Could this have been orthodromic AVRT? I dont think so, as I said, it initiated with a PAC.

 

However, I still don’t understand why LBB was refractory instead of the RBB, it’s usually the other way around.

 

Thanks and Kind Regards

Arman Bajwa