A Case of Wide Complex Tachycardia
Presented By:
Kavitha Arulmozhi, MD; Lerraughn Morgan, DO; Bianca Castellanos, MD; Scott Ceresnak, MD
Valley Children's Healthcare; Lucile Packard Children's Hospital, Stanford University School of Medicine
karulmozhi1@valleychildrens.orgOverview:
Background: The differential diagnosis for wide complex tachycardia (WCT) is broad, including supraventricular tachycardia (SVT) and ventricular dysrhythmias. We present a case of a symptomatic teenage female found to have a WCT. On electrophysiology study (EPS), she was found to have atrioventricular reentrant tachycardia (AVRT) from a concealed right-sided accessory pathway and atrioventricular nodal reentrant tachycardia (AVNRT) that required radiofrequency and cryoablation, respectively. This case elucidated the importance of prompt identification, consultation and management for aberrant SVT.
Objective: 15 year-old female presented with palpitations, chest pain, shortness of breath and dizziness while swimming. In the Emergency Department, her heart rate was 220bpm. Cardiac exam was otherwise normal. An electrocardiogram showed a WCT, left bundle branch block, and superiorly oriented QRS complex. Following a saline bolus, heart rate decreased to 107 bpm and patient self-converted to sinus rhythm. In the pediatric ICU, atenolol 25mg twice daily was initiated. Echocardiogram was normal. Upon discharge, a 30-day event monitor was placed and patient was continued on atenolol. The patient eventually consented to an invasive electrophysiology study.
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Results: Differential diagnosis based on the patient's symptoms and EKG findings included SVT with aberrant conduction, Mahaim fiber tachycardia, or atriofascicular tachycardia. Intraoperative findings were significant for two distinct substrates causing orthodromic reciprocating tachycardia (ORT). The first substrate was an AVRT from a concealed, right-sided accessory pathway, which was amenable to radiofrequency ablation. The second substrate was typical AVNRT, which underwent successful cryoablation. The patient experienced occasional palpitations shortly after the procedure, but repeat electrocardiogram and Holter monitor were normal. Annual follow-up was recommended.
Conclusions: The differential diagnosis of pediatric WCT ranges from genetic causes such as long QT syndrome, Brugada syndrome, cardiomyopathies, acquired conditions such as infectious myocarditis and stimulant ingestion. As seen in our patient, WCT can also be due to aberrant conduction of atrial tachyarrhythmia. While conditions such as Wolff-Parkinson-White syndrome have a known predisposition to ventricular fibrillation, other etiologies of SVT such as AVNRT, ectopic atrial tachycardia and concealed accessory pathway with AVRT have a low risk to develop ventricular tachyarrhythmia. Prompt recognition, expert consultation, and medical treatment are a cornerstone to SVT management. Invasive EPS with curative ablation of SVT substrate offers a potentially permanent solution.
Objective: 15 year-old female presented with palpitations, chest pain, shortness of breath and dizziness while swimming. In the Emergency Department, her heart rate was 220bpm. Cardiac exam was otherwise normal. An electrocardiogram showed a WCT, left bundle branch block, and superiorly oriented QRS complex. Following a saline bolus, heart rate decreased to 107 bpm and patient self-converted to sinus rhythm. In the pediatric ICU, atenolol 25mg twice daily was initiated. Echocardiogram was normal. Upon discharge, a 30-day event monitor was placed and patient was continued on atenolol. The patient eventually consented to an invasive electrophysiology study.
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Results: Differential diagnosis based on the patient's symptoms and EKG findings included SVT with aberrant conduction, Mahaim fiber tachycardia, or atriofascicular tachycardia. Intraoperative findings were significant for two distinct substrates causing orthodromic reciprocating tachycardia (ORT). The first substrate was an AVRT from a concealed, right-sided accessory pathway, which was amenable to radiofrequency ablation. The second substrate was typical AVNRT, which underwent successful cryoablation. The patient experienced occasional palpitations shortly after the procedure, but repeat electrocardiogram and Holter monitor were normal. Annual follow-up was recommended.
Conclusions: The differential diagnosis of pediatric WCT ranges from genetic causes such as long QT syndrome, Brugada syndrome, cardiomyopathies, acquired conditions such as infectious myocarditis and stimulant ingestion. As seen in our patient, WCT can also be due to aberrant conduction of atrial tachyarrhythmia. While conditions such as Wolff-Parkinson-White syndrome have a known predisposition to ventricular fibrillation, other etiologies of SVT such as AVNRT, ectopic atrial tachycardia and concealed accessory pathway with AVRT have a low risk to develop ventricular tachyarrhythmia. Prompt recognition, expert consultation, and medical treatment are a cornerstone to SVT management. Invasive EPS with curative ablation of SVT substrate offers a potentially permanent solution.
