Palpitations all the Time: Difference between revisions

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m (New page: {{NHJ| |mainauthor= '''A.A.M. Wilde, R.B.A. van den Brink''' |edition= 2007:5,198 }} Figure 1|thumb A 14-year-old girl complained of palpitations that...)
 
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[[Puzzle_2007_5_198_Answer|Answer]]
[[Puzzle_2007_5_198_Answer|Answer]]
The left part of the ECG shows a narrow complex
tachycardia with a rate of 200 beats/min (RR interval
320 ms). At first glance a P wave is not clearly discernable.
After five cycles, the tachycardia suddenly stops
and four multiform complexes are seen without any P
waves. These complexes should be regarded as a polymorphic
ventricular tachycardia, which is not uncommon
after an adenosine-terminated supraventricular
tachycardia.<cite>Tan</cite> A fifth complex is preceded by a P wave.
The subsequent four complexes are morphologically
similar, all show a widened QRS complex and all are
immediately preceded by a P wave. The initial phase
of the QRS complex is slurred and positive in all available
leads. Sinus rhythm continues thereafter with
gradual abbreviation of the QRS complex until a 120
msec wide QRS complex remains. A close look reveals
that the PQ interval remains short and that the initial
phase of these QRS complexes is still slurring.
All tachycardias that include the AV node in their
circuit are sensitive to adenosine. This includes AV
nodal reentrant tachycardia and AV reentrant tachycardia.
Conduction through the AV node is temporarily
blocked by adenosine and the fact that AV conduction
is still present (the four similar wide QRS complexes
preceded by a P wave) suggests the presence of an
alternative AV connection. (i.e. a Kent bundle). After
restoration of the AV node both pathways are used.
Hence, the initial polymorphic ventricular tachycardia
is followed by restoration of sinus rhythm, initially
exclusively conducted over an accessory pathway,
followed by preexcitation and normal AV conduction.
Figure 2 shows the ECG during sinus rhythm. A
discrete Δ wave is clearly visible. The morphology of
the Δ wave suggests a left posterior Kent bundle.
'''Conclusion: Wolff-Parkinson-White syndrome with an orthodromic circus movement tachycardia and under the influence of adenosine temporarily exclusive preexcitation.'''
==References==
<biblio>
#Tan pmid=11341081
</biblio>

Revision as of 20:35, 8 October 2007

Author(s) A.A.M. Wilde, R.B.A. van den Brink
NHJ edition: 2007:5,198
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

A 14-year-old girl complained of palpitations that occurred numerous times a week. There were no special triggers and, usually, by deep breathing she was able to stop it. During one of the episodes she visited the emergency department. Physical examination revealed no abnormalities with exception of a fast regular pulse (185 beats/min). A deep breathhold did not stop the tachycardia this time and adenosine was administered intravenously. The ECG (leads I, II, V1 to V6) shortly after the bolus adenosine is shown in figure 1.

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