Five Years of Palpitations: Difference between revisions

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 [[Puzzle_2007_6_231_Answer|Answer]]
-[[Image:Puzzle_2007_6_231_fig2.png|Figure 2|thumb]]
-[[Image:Puzzle_2007_6_231_fig3.jpg|Figure 3|thumb]]
-The first part of the ECG shows sinus rhythm with a
-regular rate of 130 beats/min. Four sinus P waves are
-followed by normal ventricular activation with a normal
-PR interval. The T wave of the 4th sinus beat is
-different to the preceding ones suggesting
-superimposement of a P wave (arrow 1 in figure 2 and
-very well seen in lead V1 of figure 1) which is
-subsequently conducted with a prolonged PR interval
-to the ventricle. A short supraventricular tachycardia
-(SVT) is initiated with a rate of 210 beats/min. A clear
-P wave is not observed in or related to the subsequent
-ventricular activation. After three beats a left bundle
-branch block (LBBB) complex is observed which
-might have been conducted from regular
-supraventricular activation. In the distal part of the ST
-segment, there is a clear sinus node P wave (figure 2,
-arrow 2) conducted through the atrioventricular node
-with a long PR interval, in turn followed by an RBBB
-tachycardia with the same frequency as the SVT shortly
-before.
-In both cases the tachycardia is initiated by a
-prolonged PR interval which is highly suggestive of
-slow pathway conduction through the AV node.
-Hence, AV nodal reentrant tachycardia (AVNRT) is
-the most likely diagnosis in the second part of the ECG
-with aberrant conduction over the right bundle. The
-peculiarity in this ECG is the initiation of the second
-part by a sinus node beat (not a supraventricular
-extrasystole).
-On invasive electrophysiological study AVNRT
-tachycardia was confirmed. Figure 3 shows two
-extremity leads, lead V1, five coronary sinus leads and
-recordings from the mapping catheter, which is in the
-right ventricle (100 mm/s). Two atrial extrasystoles
-are given (middle part of the recording) which conduct
-slowly to the ventricles and, on the right side of the
-recording, are followed by a spontaneous rhythm in
-which the QRS complex is immediately followed by the
-atrial depolarisation. This is highly suggestive of AV
-nodal reentrant tachycardia.
-'''Conclusion: AVNRT induced by atrial extrasystoles and by a sinus beat. RBBB aberrant conduction. The LBBB beat is probably LBBB aberrant conduction or a ventricular extrasystole.'''