Rhythm
puzzle
T.A. Simmers, A.A.M. Wilde
Figure 1. A long RP Supraventricular tachycardla This ECG was taken from an otherwise healthy 19-
year-old male, without apparent structural heart disease but with frequent and extended attacks ofpalpitations. He could influence neither onset nor termination of an attack. Treatment with a ,-blocker and with verapamil had been unsuccessfuil; he was referred for nonpharmacological treatment. The ECG shows a narrow QRS tachycardia at a rate of 140 beats/min. There is a 1:1 P:QRS relationship (P waves can be readily identified in leads V1, aVR and the inferior leads in particular), with a superior P-wave T.A. Simmers. A.A.M. Wilde. Academic Medical Centre, Amsterdam. Address for correspondence: Dr. T.A. Simmers.
E-mail:[email protected]
274
axis (P waves are negative in the inferior leads and positive in aVR and V1). The RP interval is dearly longer than the PRinterval. Several differential diagnoses are possible: 1. atypical AV nodal reentry tachycardia, 2. atrial tachycardia, or 3. PJRT (permanent form of junctional reciprocating tachycardia). In atypical type AV nodal reentry tachycardia, anterograde conduction is via the 'fast pathway' and retrograde conduction via the 'slow pathway' in a patient with dual AV nodal physiology. This would explain both the short PR/long RP intervals and P-wave axis, with retrograde atrial activation coming from the lower right atrium. This could also be a posteroseptal atrial tachycardia; again, P-wave axis might suggest this. The mode of tachycardia initiation, spontaneously or at electrophysiological study, presence or absence of dual AV nodal physiology and mode oftermination would help to differentiate between these two diagnoses. Answer You will find the answer on page 286. e Netherlands Heart Journal, Volume 11, Number 6, June 2003
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Heart Failure 2003 Intemational Meeting of the Working Group on Heart Failure (ESC) and the Annual Congress of the European Section of the Intermational Society for Heart Research Strasbourg, France, 21-24 June 2003 The European Society of Cardiology, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis Cedex France, tel.: +33 49 294 76 00, fax: +33 49 294 76 01
25th Congress of the European Society of Cardiology Vienna, Austria, 30 August-3 September 2003 The European Heart House, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis Cedex, France, tel.: +33 49 294 76 00, fax: +33 49 294 7601
Frst Eureglonal Symposium on Imaging and Arrhythmias Maastricht, 2-4 October 2003 The European Heart House, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis Cedex, France, tel.: +33 49 294 76 00, fax: +33 49 294 7601 Controversies In Adult Cardiac Surgery Los Angeles, US, 4-5 October 2003 Promedica International, Huntington Beach, California 92647, United States, tel.: +1 714 799 1617, fax: +1 714 799 1686, e-mail: [email protected]
53rd Annual Scientific Session of the American College of Cardiology New Orleans, US, 7-10 March 2004 American College of Cardiology, 9111 Georgetown Rd., Bethesda, US, fax: +1 301 897 9745, www.acc.org
The 19th Annual Interventional Cardiology 2004: The Intemational Symposium Snowmass Village, Colorado USA, 22-26 March 2004 Contact: Promedica International, a California Corporation, 7777 CenterAvenue, Suite 500, Huntington Beach, CA 92647 USA, tel.: +1 714 799-1617 Ext. 3, fax: +1 799-1686, E-mail: [email protected], Website: http://www.promedica-intl.com
26th Congress of the European Society of Cardiology Munich, Germany, 28 August-I September 2004 The European Heart House, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis Cedex, France, tel.: +3349 294 7600,fax: +33 49 294 7601 77th Scientiflc Session, American Heart Association (AHA) New Orkans, USA, 7-10 November 2004 For information, contact:American Heart Association, 7320 Greenville Avenue, Dallas, Texas 75231, Phone: 1 214 373-6300, Fax: 1 214 373-3406
8th Intemational Workshop on Cardiac Arrhythmias Venice, Italy, 5-8 October2003 Fax +39 0541 305849, e-mail: [email protected],
http://www.venicearrhythrnias.org/ 76th Annual Meeting of the American Heart
Association Orlando, Florida, 9-12 November 2003 American Heart Association, Scientific and Corporate Meetings, 7272 Greenville Avenue, Dallas, US, tel.: +1 214 706 12 53, fax: +1 214 272 34 06 The European Chapter of Ls Club Mftrabe Paris, France, 3-5 December 2003 Promedica International, Huntington Beach, California 92647, United States, tel.: +1 714 799 1617 ext. 26, fax: +1 714 799 1686, e-mail: [email protected] http ://www.promedica-intl.com/Promedica-
Education/lcml12-3-03.htm
286
Answer to Rhythm puzle (page 274) The young age oftthe patient and incessant character ofthe arrhythmia, in addition to P-wave morphology (superior axis) and timing (RP>PR) are all typical of the third and in this case correct diagnosis: permanent form ofjunctional reciprocating tachycardia (PJRT). This entity, also associated with the name of Coumel, is a form of circus movement tachycardia: anterograde conduction is via the normal conduction system, the retrograde limb of the reentrant circuit is a posteroseptal concealed bypass with decremental, AV node-like conduction properties. The diagnosis was confirmed by electrophysiological study, and the differential diagnoses of atypical AV nodal reentry tachycardia and atrial tachycardia thus rejected. The patient underwent successful catheter ablation. c
Netherlands Hcart Joumal, Volumc 11, Number 6, Junc 2003
puzzle
T.A. Simmers, A.A.M. Wilde
Figure 1. A long RP Supraventricular tachycardla This ECG was taken from an otherwise healthy 19-
year-old male, without apparent structural heart disease but with frequent and extended attacks ofpalpitations. He could influence neither onset nor termination of an attack. Treatment with a ,-blocker and with verapamil had been unsuccessfuil; he was referred for nonpharmacological treatment. The ECG shows a narrow QRS tachycardia at a rate of 140 beats/min. There is a 1:1 P:QRS relationship (P waves can be readily identified in leads V1, aVR and the inferior leads in particular), with a superior P-wave T.A. Simmers. A.A.M. Wilde. Academic Medical Centre, Amsterdam. Address for correspondence: Dr. T.A. Simmers.
E-mail:[email protected]
274
axis (P waves are negative in the inferior leads and positive in aVR and V1). The RP interval is dearly longer than the PRinterval. Several differential diagnoses are possible: 1. atypical AV nodal reentry tachycardia, 2. atrial tachycardia, or 3. PJRT (permanent form of junctional reciprocating tachycardia). In atypical type AV nodal reentry tachycardia, anterograde conduction is via the 'fast pathway' and retrograde conduction via the 'slow pathway' in a patient with dual AV nodal physiology. This would explain both the short PR/long RP intervals and P-wave axis, with retrograde atrial activation coming from the lower right atrium. This could also be a posteroseptal atrial tachycardia; again, P-wave axis might suggest this. The mode of tachycardia initiation, spontaneously or at electrophysiological study, presence or absence of dual AV nodal physiology and mode oftermination would help to differentiate between these two diagnoses. Answer You will find the answer on page 286. e Netherlands Heart Journal, Volume 11, Number 6, June 2003
~~~~~~~~~~~~-
a.gW
iG
E
. S'-it:|g-rdt
.xq:..4.W! . . . . . . . . . . . . . . . . . E. .x}@'.gm.i-%].S-t.>
Heart Failure 2003 Intemational Meeting of the Working Group on Heart Failure (ESC) and the Annual Congress of the European Section of the Intermational Society for Heart Research Strasbourg, France, 21-24 June 2003 The European Society of Cardiology, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis Cedex France, tel.: +33 49 294 76 00, fax: +33 49 294 76 01
25th Congress of the European Society of Cardiology Vienna, Austria, 30 August-3 September 2003 The European Heart House, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis Cedex, France, tel.: +33 49 294 76 00, fax: +33 49 294 7601
Frst Eureglonal Symposium on Imaging and Arrhythmias Maastricht, 2-4 October 2003 The European Heart House, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis Cedex, France, tel.: +33 49 294 76 00, fax: +33 49 294 7601 Controversies In Adult Cardiac Surgery Los Angeles, US, 4-5 October 2003 Promedica International, Huntington Beach, California 92647, United States, tel.: +1 714 799 1617, fax: +1 714 799 1686, e-mail: [email protected]
53rd Annual Scientific Session of the American College of Cardiology New Orleans, US, 7-10 March 2004 American College of Cardiology, 9111 Georgetown Rd., Bethesda, US, fax: +1 301 897 9745, www.acc.org
The 19th Annual Interventional Cardiology 2004: The Intemational Symposium Snowmass Village, Colorado USA, 22-26 March 2004 Contact: Promedica International, a California Corporation, 7777 CenterAvenue, Suite 500, Huntington Beach, CA 92647 USA, tel.: +1 714 799-1617 Ext. 3, fax: +1 799-1686, E-mail: [email protected], Website: http://www.promedica-intl.com
26th Congress of the European Society of Cardiology Munich, Germany, 28 August-I September 2004 The European Heart House, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis Cedex, France, tel.: +3349 294 7600,fax: +33 49 294 7601 77th Scientiflc Session, American Heart Association (AHA) New Orkans, USA, 7-10 November 2004 For information, contact:American Heart Association, 7320 Greenville Avenue, Dallas, Texas 75231, Phone: 1 214 373-6300, Fax: 1 214 373-3406
8th Intemational Workshop on Cardiac Arrhythmias Venice, Italy, 5-8 October2003 Fax +39 0541 305849, e-mail: [email protected],
http://www.venicearrhythrnias.org/ 76th Annual Meeting of the American Heart
Association Orlando, Florida, 9-12 November 2003 American Heart Association, Scientific and Corporate Meetings, 7272 Greenville Avenue, Dallas, US, tel.: +1 214 706 12 53, fax: +1 214 272 34 06 The European Chapter of Ls Club Mftrabe Paris, France, 3-5 December 2003 Promedica International, Huntington Beach, California 92647, United States, tel.: +1 714 799 1617 ext. 26, fax: +1 714 799 1686, e-mail: [email protected] http ://www.promedica-intl.com/Promedica-
Education/lcml12-3-03.htm
286
Answer to Rhythm puzle (page 274) The young age oftthe patient and incessant character ofthe arrhythmia, in addition to P-wave morphology (superior axis) and timing (RP>PR) are all typical of the third and in this case correct diagnosis: permanent form ofjunctional reciprocating tachycardia (PJRT). This entity, also associated with the name of Coumel, is a form of circus movement tachycardia: anterograde conduction is via the normal conduction system, the retrograde limb of the reentrant circuit is a posteroseptal concealed bypass with decremental, AV node-like conduction properties. The diagnosis was confirmed by electrophysiological study, and the differential diagnoses of atypical AV nodal reentry tachycardia and atrial tachycardia thus rejected. The patient underwent successful catheter ablation. c
Netherlands Hcart Joumal, Volumc 11, Number 6, Junc 2003
