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Gepubliceerd in: Netherlands Heart Journal 4/2022

Open Access 25-02-2022 | Rhythm Puzzle – Answer

Atrial fibrillation and what else?

Auteurs: S. M. van den Bogaard, F. E. Vervaat, P. H. van der Voort

Gepubliceerd in: Netherlands Heart Journal | Uitgave 4/2022

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Answer

Initially, the bursts of wide complex tachycardia were diagnosed as non-sustained ventricular tachycardia (VT); however, higher doses of beta blocker increased the occurrence of wide complex tachycardia, without affecting the heart rate in atrial fibrillation (AF). The respiratory condition of the patient deteriorated further during the hospital stay, necessitating transfer to the intensive care unit, intubation and initiation of mechanical ventilation. To optimise the haemodynamic state, transoesophageal echocardiography-guided electrical cardioversion was performed after left atrial appendage thrombosis had been excluded. The electrical cardioversion was successful with restoration of sinus rhythm (Fig. 1).
The electrocardiogram during sinus rhythm now revealed ventricular pre-excitation over a left-sided accessory pathway (AP). The patient’s first electrocardiogram (see Fig. 1a in the Question) had shown AF with exclusively narrow QRS complexes; antegrade conduction over the AP was concealed by retrograde (partial) conduction in the AP. Beta blockers slowed the conduction in the AV node, decreasing retrograde concealment and facilitating antegrade conduction over the AP (see Fig. 1b in the Question) [1].
Beta blockers have been shown to increase ventricular rate [2]. Potential mechanisms include (1) direct shortening of the AP refractory period, which is unlikely [3], (2) indirect shortening of the refractory period by catecholamines and (3) decreased concealed conduction [2]. In the current guidelines, beta blockers are contra-indicated in patients with pre-excitation and AF for this reason. After cardioversion, the patient remained in sinus rhythm, but he died from pulmonary complications of COVID-19.

Conflict of interest

S.M. van den Bogaard, F.E. Vervaat and P.H. van der Voort declare that they have no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
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Netherlands Heart Journal

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Literatuur
1.
go back to reference Klein GJ, Yee R. Sharma AD Concealed conduction in accessory atrioventricular pathways: an important determinant of the expression of arrhythmias in patients with Wolff-Parkinson-White syndrome. Circulation. 1984;70:402–11.CrossRef Klein GJ, Yee R. Sharma AD Concealed conduction in accessory atrioventricular pathways: an important determinant of the expression of arrhythmias in patients with Wolff-Parkinson-White syndrome. Circulation. 1984;70:402–11.CrossRef
2.
go back to reference Morady F, Dicarlo LA, Baerman JM, de Buitleir M. Effect of propranolol on ventricular rate during atrial fibrillation in the Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol. 1987;10(3 Pt 1):492–6.CrossRef Morady F, Dicarlo LA, Baerman JM, de Buitleir M. Effect of propranolol on ventricular rate during atrial fibrillation in the Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol. 1987;10(3 Pt 1):492–6.CrossRef
3.
go back to reference Denes P, Cummings JM, Simpson R, et al. Effects of propanolol on anomalous pathway refractoriness and circus movement tachycardias in patients with preexcitation. Am J Cardiol. 1978;41:1061–7.CrossRef Denes P, Cummings JM, Simpson R, et al. Effects of propanolol on anomalous pathway refractoriness and circus movement tachycardias in patients with preexcitation. Am J Cardiol. 1978;41:1061–7.CrossRef
Metagegevens
Titel
Atrial fibrillation and what else?
Auteurs
S. M. van den Bogaard
F. E. Vervaat
P. H. van der Voort
Publicatiedatum
25-02-2022
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 4/2022
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-022-01669-9

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Rhythm Puzzle – Question

Atrial fibrillation and what else?