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[[Puzzle_2005_12_466 - Answer|Answer]]
[[Puzzle_2005_12_466 - Answer|Answer]]
The patient’s ECG in sinus rhythm demonstrates right
bundle branch block, but more remarkably an extreme
prolongation and fragmentation of the terminal
portion of the QRS complex. In addition, the QRS
complex in V1 has an initial Q wave. This combination
of findings should suggest significant right ventricular
overload and conduction delay. In and of itself, this must
suggest some form of right ventricular disease. During
tachycardia, QRS morphology is unchanged, indicating
supraventricular tachycardia (SVT), but the original
P wave is absent. Close examination, as illustrated in
figure 3, reveals low amplitude and highly fragmented
P waves, negative in V1 with a superior axis, cycle length
280 ms with 3:1 AV conduction. P-wave morphology
also indicates right-sided pathology. All in all, this combination
of right ventricular conduction abnormality
and right atrial tachycardia should suggest a congenital
heart defect involving the right heart. This was indeed
the case in this patient: she had undergone correction
of secundum type atrial septal defect at a young age.
More importantly in light of onset of symptoms in
2002, tricuspid valve reconstruction was performed in
that year because of Ebstein’s anomaly.
Ebstein’s anomaly is a relatively rare condition,
accounting for no more than approximately 0.5% of
congenital heart defects. It is characterised by an
abnormal septal leaflet of the tricuspid valve with apical
displacement, leading to atrialisation of part of the right
ventricle.<cite>Wu</cite> While morphological and subsequent
haemodynamic consequences may be mild, severe
tricuspid regurgitation also occurs, as was the case in
this patient and the reason for her surgery. Considerable
conduction delay in this atrialised and dilated
portion of the right ventricle has been demonstrated
to cause QRS fragmentation and prolongation in classic
electrophysiological studies<cite>Kaster</cite> and more recently signalaveraged
ECG;<cite>Tede</cite> figure 1 is a classical example of this
phenomenon. Onset of atrial arrhythmias in such close
conjunction to cardiac surgery involving right atrial
atriotomy must inevitably raise the suspicion of postincisional
atrial tachycardia. This diagnosis was confirmed
at electrophysiological study.
==References==
<biblio>
#Wu pmid=15536453
#Kastor pmid=1182962
#Tede pmid=14969616
</biblio>

Latest revision as of 20:02, 25 January 2010

Author(s) T.A. Simmers, A.A.M. Wilde
NHJ edition: 2005:12,466
These Rhythm Puzzles have been published in the Netherlands Heart Journal and are reproduced here under the prevailing creative commons license with permission from the publisher, Bohn Stafleu Van Loghum.
The ECG can be enlarged twice by clicking on the image and it's first enlargement
Figure 1
Figure 2
Figure 3

A 63-year-old female was referred to our outpatient clinic with symptoms of palpitations. These had been occurring in paroxysms since 2002, and were highly drug refractory; she had undergone numerous DC cardioversions. Her ECG in sinus rhythm is shown in figure 1, during symptoms in figure 2, with a blowup in figure 3. Her prior history provides the solution to the following questions, which you might nonetheless try to answer without additional information.

  1. What diagnoses could the ECG in sinus rhythm suggest?
  2. What is your interpretation of figure 2 (aided by figure 3)?

Answer

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