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Gepubliceerd in: Netherlands Heart Journal 10/2021

Open Access 03-08-2021 | Rhythm Puzzle – Answer

Tachycardia in a teenager

Auteurs: Y. R. Persia-Paulino, J. Rozado, D. Perez

Gepubliceerd in: Netherlands Heart Journal | Uitgave 10/2021

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Answer

The electrocardiogram on admission shows a regular tachycardia of approximately 162 beats/min with a relatively narrow QRS complex (116 ms) with a right bundle branch block (RBBB) morphology and left axis deviation (LAD). Atrioventricular dissociation can be seen (Fig. 1; green arrow shows P waves, which are not related in rhythm or frequency to QRS complexes). These findings are consistent with an idiopathic left ventricular tachycardia (ILVT) originating in the left posterior fascicle (which explains the RBBB and LAD in such a young patient). It is a re-entry tachycardia involving the interventricular septum, the apex and one of the left fascicles of the bundle of His (in this case, the left posterior fascicle, which is involved most frequently) [1].
ILVT is usually seen in patients aged 15–40 years with structurally normal hearts and has a low risk of sudden death (although deaths have been reported). Episodes usually occur at rest, but are influenced by exercise and emotional stress. Verapamil is usually effective in ending ILVT and preventing new episodes. Radiofrequency catheter ablation (RFCA) is an option for patients intolerant to antiarrhythmic drugs or with severe symptoms [2]. RFCA of ILVT has an overall success rate of 95% [3], but changes in surface ECG can occur, specifically the development of a Q wave on inferior leads and, less frequently, a left posterior fascicular block (as this fascicle, which is part of the tachycardia circuit, could be damaged) in approximately 10% of patients [4].
In wide QRS complex tachycardia, atrioventricular (AV) dissociation is a criterion that has been reported to have a 100% positive predictive value [5]. For differential diagnosis between supraventricular and ventricular tachycardia, the Brugada algorithm is very useful, as in this case AV dissociation is the only criterion met.

Conflict of interest

Y.R. Persia-Paulino, J. Rozado and D. Perez 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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Literatuur
1.
go back to reference Prystowsky EN, Padanilam BJ, Joshi S, Fogel RI. Ventricular arrhythmias in the absence of structural heart disease. J Am Coll Cardiol. 2012;59:1733–44. CrossRef Prystowsky EN, Padanilam BJ, Joshi S, Fogel RI. Ventricular arrhythmias in the absence of structural heart disease. J Am Coll Cardiol. 2012;59:1733–44. CrossRef
2.
go back to reference Badhwar N, Scheinman MM. Idiopathic ventricular tachycardia: diagnosis and management. Curr Probl Cardiol. 2007;32:7–43. CrossRef Badhwar N, Scheinman MM. Idiopathic ventricular tachycardia: diagnosis and management. Curr Probl Cardiol. 2007;32:7–43. CrossRef
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go back to reference Schreiber D, Kottkamp H. Ablation of idiopathic ventricular tachycardia. Curr Cardiol Rep. 2010;12:382–8. CrossRef Schreiber D, Kottkamp H. Ablation of idiopathic ventricular tachycardia. Curr Cardiol Rep. 2010;12:382–8. CrossRef
4.
go back to reference Yao SY, Chu JM, Fang PH, Zhang KJ, Ma J, Zhang S. The morphology changes in limb leads after ablation of verapamil-sensitive idiopathic left ventricular tachycardia and their correlation with recurrence. J Cardiovasc Electrophysiol. 2008;19:238–41. CrossRef Yao SY, Chu JM, Fang PH, Zhang KJ, Ma J, Zhang S. The morphology changes in limb leads after ablation of verapamil-sensitive idiopathic left ventricular tachycardia and their correlation with recurrence. J Cardiovasc Electrophysiol. 2008;19:238–41. CrossRef
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go back to reference Garner JB, Miller JM. Wide complex tachycardia—ventricular tachycardia or not ventricular tachycardia, that remains the question. Arrhythm Electrophysiol Rev. 2013;2:23–9. CrossRef Garner JB, Miller JM. Wide complex tachycardia—ventricular tachycardia or not ventricular tachycardia, that remains the question. Arrhythm Electrophysiol Rev. 2013;2:23–9. CrossRef
Metagegevens
Titel
Tachycardia in a teenager
Auteurs
Y. R. Persia-Paulino
J. Rozado
D. Perez
Publicatiedatum
03-08-2021
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 10/2021
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-021-01611-5

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Rhythm Puzzle – Question

Tachycardia in a teenager