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Gepubliceerd in: Netherlands Heart Journal 2/2019

Open Access 14-12-2018 | Rhythm Puzzle – Answer

An irregular narrow complex tachycardia: atrial fibrillation or something else?

Auteurs: M. J. Mulder, C. P. Allaart, H. A. Hauer, M. J. B. Kemme

Gepubliceerd in: Netherlands Heart Journal | Uitgave 2/2019

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Answer

The intracardiac recording during tachycardia (Fig. 1) shows a regular atrial rhythm, excluding atrial fibrillation. His bundle activation precedes ventricular activation and there is atrioventricular dissociation. The main differential diagnosis comprises atrioventricular node reentrant tachycardia (AVNRT), which may occur without atrial activation, and focal junctional tachycardia (FJT). Distinction is possible by analysing the response to a sinus beat which occurs before junctional depolarisation when the His bundle is non-refractory. Normal conduction of the sinus beat excludes AVNRT with bidirectional AH block. The sinus beat is conducted down the fast AV nodal pathway, leading to advancement of His bundle and ventricular activation without terminating or resetting the tachycardia. In common type (slow-fast) AVNRT, the subsequent refractoriness of the fast pathway would terminate the tachycardia. In contrast, termination is not expected during FJT, because of its focal nature [1]. Therefore, this tachycardia was diagnosed as FJT.
FJT is a rare arrhythmia in adults and is characterised by a rapid heart rate, narrow QRS complexes and atrioventricular dissociation. Frequently, an irregular rhythm is present which could lead to misdiagnosis of atrial fibrillation. The response to antiarrhythmic drugs is usually poor. Ablation is considered an effective alternative [2]. In this patient, after diagnosis of FJT, radiofrequency energy was delivered in the lower two-thirds of the Koch’s triangle, during which the tachycardia converted to sinus rhythm. Atrioventricular conduction was preserved. She remained free of symptoms during 3 months of follow-up.

Conflict of interest

M.J. Mulder, C.P. Allaart, H.A. Hauer and M.J.B. Kemme declare that they have no competing interests.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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Literatuur
1.
go back to reference Padanilam BJ, Manfredi JA, Steinberg LA, Olson JA, Fogel RI, Prystowsky EN. Differentiating junctional tachycardia and atrioventricular node re-entry tachycardia based on response to atrial extrastimulus pacing. J Am Coll Cardiol. 2008;52:1711–7. CrossRef Padanilam BJ, Manfredi JA, Steinberg LA, Olson JA, Fogel RI, Prystowsky EN. Differentiating junctional tachycardia and atrioventricular node re-entry tachycardia based on response to atrial extrastimulus pacing. J Am Coll Cardiol. 2008;52:1711–7. CrossRef
2.
go back to reference Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Supraventricular Arrhythmias). Circulation. 2003;108:1871–909. CrossRef Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Supraventricular Arrhythmias). Circulation. 2003;108:1871–909. CrossRef
Metagegevens
Titel
An irregular narrow complex tachycardia: atrial fibrillation or something else?
Auteurs
M. J. Mulder
C. P. Allaart
H. A. Hauer
M. J. B. Kemme
Publicatiedatum
14-12-2018
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 2/2019
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-018-1217-y

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