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 [[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
-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
-, 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>