Author's Accepted Manuscript
Young Woman with Palpitations and Pre-excitation Mark E. Josephson MD, Hein J.J. Wellens MD
PII: DOI: Reference:
S1547-5271(15)00541-X http://dx.doi.org/10.1016/j.hrthm.2015.04.031 HRTHM6248
To appear in:
Heart Rhythm
www.elsevier.com/locate/buildenv
Cite this article as: Mark E. Josephson MD, Hein J.J. Wellens MD, Young Woman with Palpitations and Pre-excitation, Heart Rhythm, http://dx.doi.org/10.1016/j. hrthm.2015.04.031 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Young Woman with Palpitations and Pre-excitation Mark E. Josephson, MD1 and Hein J.J. Wellens, MD2 1
Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 2
Cardiovascular Research Institute, Maastricht, The Netherlands
Corresponding Author: Dr. Mark E. Josephson, MD Beth Israel Deaconess Medical Center Division of Cardiology 185 Pilgrim Road Baker 4 Boston, MA 02215 [email protected]
1
Young Woman with Palpitations and Pre-excitation
A 24 year old woman came to the clinic with a history of palpitations. She had no syncope and no sensations of pulsations in her neck or shortness of breath. She admitted to being under stress at work. An ECG was performed which is shown in Figure 1 had slurring at the onset of her QRS suggestive of pre-excitation.
Question: Based on the ECG where is the pathway located? Discussion: The first observation is that there is minimal pre-excitation and the P wave is completed before the onset of the delta wave which is positive in the inferior leads. There is an isoelectric or minimally positive delta in V 1 with an abrupt transition to positive in V2. The QRS is only 90 msec wide with an axis of +70°. This combination is not really compatible with a right or left free wall pathway or an antero- or posteroseptal pathway. While a mid-septal pathway is possible it would have to have decremental properties to have a completed P wave before the onset of the delta wave. A fasciculoventricular pathway should be considered since it takes off after the His bundle is activated. The results of carotid sinus massage (CSM) shown in Figure 2 confirmed the diagnosis of a fasciculoventricular pathway by producing PR prolongation and no change in preexcitation. 2
Useful diagnostic maneuvers for a fasciculoventricular pathway are those that slow AV nodal conduction (ie. CSM or valsalva,, adenosine, or a beta or calcium channel blocker) which would prolong the PR and not change the degree of preexcitation. An electrophysiology study confirmed a fascicoloventricular pathway (fixed, short HV, pacing induced prolongation of A-V nodal conduction with no change in preexcitation). No arrhythmias were induced. Long term monitoring demonstrated her palpitations were due to sinus tachycardia. Fasciculoventricular pathways are not known to participate in reentrant tachycardias, but they may exist as innocent bystanders during other tachycardias. As such no attempt to ablate them should be made.
3
Figure Legends
Figure 1: Sinus Rhythm ECG During sinus rhythm there is minimal slurring of the QRS which begins after the P wave. The QRS is relatively narrow (90 msec) and has an axis of +60. There is an abrupt transition of the delta wave to positive in V2.
Figure 2: Effect of Carotid Sinus Massage (CSM) During CSM the PR prologs with no effect on the degree of pre-excitation.
4
Fig 1
5
Fig 2
6
Young Woman with Palpitations and Pre-excitation Mark E. Josephson MD, Hein J.J. Wellens MD
PII: DOI: Reference:
S1547-5271(15)00541-X http://dx.doi.org/10.1016/j.hrthm.2015.04.031 HRTHM6248
To appear in:
Heart Rhythm
www.elsevier.com/locate/buildenv
Cite this article as: Mark E. Josephson MD, Hein J.J. Wellens MD, Young Woman with Palpitations and Pre-excitation, Heart Rhythm, http://dx.doi.org/10.1016/j. hrthm.2015.04.031 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Young Woman with Palpitations and Pre-excitation Mark E. Josephson, MD1 and Hein J.J. Wellens, MD2 1
Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 2
Cardiovascular Research Institute, Maastricht, The Netherlands
Corresponding Author: Dr. Mark E. Josephson, MD Beth Israel Deaconess Medical Center Division of Cardiology 185 Pilgrim Road Baker 4 Boston, MA 02215 [email protected]
1
Young Woman with Palpitations and Pre-excitation
A 24 year old woman came to the clinic with a history of palpitations. She had no syncope and no sensations of pulsations in her neck or shortness of breath. She admitted to being under stress at work. An ECG was performed which is shown in Figure 1 had slurring at the onset of her QRS suggestive of pre-excitation.
Question: Based on the ECG where is the pathway located? Discussion: The first observation is that there is minimal pre-excitation and the P wave is completed before the onset of the delta wave which is positive in the inferior leads. There is an isoelectric or minimally positive delta in V 1 with an abrupt transition to positive in V2. The QRS is only 90 msec wide with an axis of +70°. This combination is not really compatible with a right or left free wall pathway or an antero- or posteroseptal pathway. While a mid-septal pathway is possible it would have to have decremental properties to have a completed P wave before the onset of the delta wave. A fasciculoventricular pathway should be considered since it takes off after the His bundle is activated. The results of carotid sinus massage (CSM) shown in Figure 2 confirmed the diagnosis of a fasciculoventricular pathway by producing PR prolongation and no change in preexcitation. 2
Useful diagnostic maneuvers for a fasciculoventricular pathway are those that slow AV nodal conduction (ie. CSM or valsalva,, adenosine, or a beta or calcium channel blocker) which would prolong the PR and not change the degree of preexcitation. An electrophysiology study confirmed a fascicoloventricular pathway (fixed, short HV, pacing induced prolongation of A-V nodal conduction with no change in preexcitation). No arrhythmias were induced. Long term monitoring demonstrated her palpitations were due to sinus tachycardia. Fasciculoventricular pathways are not known to participate in reentrant tachycardias, but they may exist as innocent bystanders during other tachycardias. As such no attempt to ablate them should be made.
3
Figure Legends
Figure 1: Sinus Rhythm ECG During sinus rhythm there is minimal slurring of the QRS which begins after the P wave. The QRS is relatively narrow (90 msec) and has an axis of +60. There is an abrupt transition of the delta wave to positive in V2.
Figure 2: Effect of Carotid Sinus Massage (CSM) During CSM the PR prologs with no effect on the degree of pre-excitation.
4
Fig 1
5
Fig 2
6
