https://en.ecgpedia.org/index.php?title=Puzzle_2005_12_466_-_Answer&feed=atom&action=historyPuzzle 2005 12 466 - Answer - Revision history2024-03-28T13:09:56ZRevision history for this page on the wikiMediaWiki 1.39.5https://en.ecgpedia.org/index.php?title=Puzzle_2005_12_466_-_Answer&diff=5166&oldid=prevDrj: New page: {{NHJ| |mainauthor= '''T.A. Simmers, A.A.M. Wilde''' |edition= 2005:12,466 }} thumb thumb [[Im...2007-10-08T17:41:57Z<p>New page: {{NHJ| |mainauthor= '''T.A. Simmers, A.A.M. Wilde''' |edition= 2005:12,466 }} <a href="/index.php?title=File:Puzzle_2005_12_466_fig1.jpg" title="File:Puzzle 2005 12 466 fig1.jpg">Figure 1|thumb</a> <a href="/index.php?title=File:Puzzle_2005_12_466_fig2.jpg" title="File:Puzzle 2005 12 466 fig2.jpg">Figure 2|thumb</a> [[Im...</p>
<p><b>New page</b></p><div>{{NHJ|<br />
|mainauthor= '''T.A. Simmers, A.A.M. Wilde'''<br />
|edition= 2005:12,466<br />
}}<br />
[[Image:Puzzle_2005_12_466_fig1.jpg|Figure 1|thumb]]<br />
[[Image:Puzzle_2005_12_466_fig2.jpg|Figure 2|thumb]]<br />
[[Image:Puzzle_2005_12_466_fig3.jpg|Figure 3|thumb]]<br />
<br />
A 63-year-old female was referred to our outpatient<br />
clinic with symptoms of palpitations. These had<br />
been occurring in paroxysms since 2002, and were<br />
highly drug refractory; she had undergone numerous<br />
DC cardioversions. Her ECG in sinus rhythm is shown<br />
in figure 1, during symptoms in figure 2, with a blowup<br />
in figure 3. Her prior history provides the solution<br />
to the following questions, which you might nonetheless<br />
try to answer without additional information.<br />
<br />
# What diagnoses could the ECG in sinus rhythm suggest? <br />
# What is your interpretation of figure 2 (aided by figure 3)?<br />
<br />
==Answer==<br />
<br />
The patient’s ECG in sinus rhythm demonstrates right<br />
bundle branch block, but more remarkably an extreme<br />
prolongation and fragmentation of the terminal<br />
portion of the QRS complex. In addition, the QRS<br />
complex in V1 has an initial Q wave. This combination<br />
of findings should suggest significant right ventricular<br />
overload and conduction delay. In and of itself, this must<br />
suggest some form of right ventricular disease. During<br />
tachycardia, QRS morphology is unchanged, indicating<br />
supraventricular tachycardia (SVT), but the original<br />
P wave is absent. Close examination, as illustrated in<br />
figure 3, reveals low amplitude and highly fragmented<br />
P waves, negative in V1 with a superior axis, cycle length<br />
280 ms with 3:1 AV conduction. P-wave morphology<br />
also indicates right-sided pathology. All in all, this combination<br />
of right ventricular conduction abnormality<br />
and right atrial tachycardia should suggest a congenital<br />
heart defect involving the right heart. This was indeed<br />
the case in this patient: she had undergone correction<br />
of secundum type atrial septal defect at a young age.<br />
More importantly in light of onset of symptoms in<br />
2002, tricuspid valve reconstruction was performed in<br />
that year because of Ebstein’s anomaly.<br />
Ebstein’s anomaly is a relatively rare condition,<br />
accounting for no more than approximately 0.5% of<br />
congenital heart defects. It is characterised by an<br />
abnormal septal leaflet of the tricuspid valve with apical<br />
displacement, leading to atrialisation of part of the right<br />
ventricle.<cite>Wu</cite> While morphological and subsequent<br />
haemodynamic consequences may be mild, severe<br />
tricuspid regurgitation also occurs, as was the case in<br />
this patient and the reason for her surgery. Considerable<br />
conduction delay in this atrialised and dilated<br />
portion of the right ventricle has been demonstrated<br />
to cause QRS fragmentation and prolongation in classic<br />
electrophysiological studies<cite>Kaster</cite> and more recently signalaveraged<br />
ECG;<cite>Tede</cite> figure 1 is a classical example of this<br />
phenomenon. Onset of atrial arrhythmias in such close<br />
conjunction to cardiac surgery involving right atrial<br />
atriotomy must inevitably raise the suspicion of postincisional<br />
atrial tachycardia. This diagnosis was confirmed<br />
at electrophysiological study.<br />
==References==<br />
<biblio><br />
#Wu pmid=15536453<br />
#Kastor pmid=1182962<br />
#Tede pmid=14969616<br />
</biblio></div>Drj