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Five Years of Palpitations: Difference between revisions
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m (New page: {{NHJ| |mainauthor= '''N.M. Panhuyzen-Goedkoop, L.R.C. Dekker, A.A.M. Wilde''' |edition= 2007:06,231 }} Figure 1|thumb A 43-year-old man came to the o...) |
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[[Puzzle_2007_6_231_Answer|Answer]] | [[Puzzle_2007_6_231_Answer|Answer]] | ||
[[Image:Puzzle_2007_6_231_fig2.jpg|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.''' | |||