A now 44-year-old man complained for about 20 years, independent of the load occurring tachycardia, the pulse rate varied between 140 and 190/Min. In the last four weeks had significantly increased the attacks - they are much longer, sometimes up to 30 minutes duration, and are terminable only with certain maneuvers. The Valsalva maneuver to try and press the gag reflex is described.
The clinical examination showed no abnormality. Resting ECG, echocardiogram and chest radiograph are normal. The laboratory results also show no abnormalities, the TSH is within normal limits.
Resting ECG. Regular sinus rhythm, frequency 66/Min, drop type, no excitation propagation or repolarization disorders (PQ 0.16, QRS 0.06, QT 0.36) in frequency 66/Min. no prolonged QT interval.
Resting ECG: sinus rhythm, drop type, no excitation propagation and repolarization disorders
Exercise ECG: bicycle ergometric stress: beginning at 50 watts, according to one watt Min./50 occurrence of tachycardia with narrow QRS complexes, ventricular rate 190/Min.
The RP-period is 220 msec, 110 msec duration of the PR. The P waves are positive in leads II, III, aVF, V2, V3, V4. An electrical alternans can be detected.
Termination of the tachycardia after 12 mg adenosine iv Thereafter AV block II ° for 2 min, after which regular sinus rhythm.
The invasive electrophysiological study supports the hypothesis of an atrio-ventricular tachycardia on the floor of accessory pathway. The accessory pathway is located in the traditional nomenclature posteroseptalen segment. Shortest retrograde connection from the ventricle to the atrium in posteroseptalen segment (CS 9/10).
The catheter ablation with radiofrequency energy terminated the tachycardia. Retrograde conduction via the accessory leader is no longer detectable, tachycardia no longer inducible. The review is not a stress-related tachycardia. An arrhythmia is no longer detectable.
In the present case is a patient with a "hidden WPW" (Concealed-WPW).
The history of sudden onset of tachycardia and sudden end, respectively, of the influence of Valsalva maneuver for the termination of the tachycardia is a typical clinical signs of atrioventricular re-entry tachycardia. Atrio-ventricular tachycardia may be present on the floor of atrioventricular nodal re-entry tachycardia (AVNRT) or atrioventricular re-entry tachycardia (AVRT). AVRT tachycardia are common enough, referred to as WPW tachycardia. In the present case is noteworthy that in the resting ECG is no indication of an accessory pathway. The PQ duration is normal, a delta-wave is not apparent. The only reference in an atrioventricular tachycardia provides the tachycardia itself Fortunately, the tachycardia was inducible in the context of the exercise test. The frequency of the tachycardia is 190/Min. The retrograde P waves are detected by the chamber complex. Here, the RP-duration longer than the PR duration. The P waves are positive in leads II, III, aVF, V2 and V3, moreover there is an electrical alternans. From this it can be diagnosed as an atrioventricular tachycardia origin. In addition to an accessory pathway, a junctional tachycardia with a 1:1 antegrade conduction to the chamber would be conceivable. The clinical signs of the termination of tachycardia by Valsalva maneuver and adenosine, however, speak against the junctional tachycardia, as well as the inability of the tachycardia to akzelerieren. Therefore, as a mechanism that remains is the AVNRT or AVRT.
In AVNRT there would be a almost a slow tachycardia. The antegrade conduction via the fast pathway, retrograde slow on. In this case, the P would be negative in the said derivatives. The positive P-wave has supported a bypass of the AV node, and this may be due to the polarity of the P-wave only in posteroseptalen area.
This example demonstrates the importance of resting ECG for diagnosis rhythmological. Although the surface ECG is no evidence for a pre-excitation, it is an accessory pathway. The tachycardia is part of "concealed WPW." The typical polarity of the P-wave during the tachycardia suggests the localization of the accessory rail. Only when these paths is the positive polarity in leads II, III, aVF, V2 and V3. Ablation was performed quickly and without complications with radiofrequency energy.
The typical diagnostic localization of the accessory pathway is based on the polarity of the delta wave. Here is the relevant literature (MS Arruda et al., Journal Cardiovasc Electrophysiol 9/2-12, 1998) pointed out. The work of Arruda is recommended because it allows in simple terms because of the polarity of the delta wave, the localization of the accessory pathway. This is worth mentioning the derivatives that are of importance for this: I, II, V1, aVF. For the left lateral frequent trains such a questionable positive or negative delta wave in V1, a positive deflection in V1 and a positivity would be too demanding in aVF, to detect a left-lateral, left anterolateral position. At this negativity in aVF were then left in the posterior or posterolateral left. These schemes allow ECG, invasive electrophysiologic investigation brief, time-saving and less stressful durchzuführ patient.
Supraventricular tachycardia; to note that electrical alternans, retrograde P wave
Left: Intracardiac ECG: Earliest retrograde excitation in the coronary sinus (CS) CS beri 9/10. Ablation at this point eliminates the accessory rail.
Right: Intracardiac ECG: right ventricular pacing after ablation - no retrograde conductio
The clinical examination showed no abnormality. Resting ECG, echocardiogram and chest radiograph are normal. The laboratory results also show no abnormalities, the TSH is within normal limits.
Resting ECG. Regular sinus rhythm, frequency 66/Min, drop type, no excitation propagation or repolarization disorders (PQ 0.16, QRS 0.06, QT 0.36) in frequency 66/Min. no prolonged QT interval.
Resting ECG: sinus rhythm, drop type, no excitation propagation and repolarization disorders
Exercise ECG: bicycle ergometric stress: beginning at 50 watts, according to one watt Min./50 occurrence of tachycardia with narrow QRS complexes, ventricular rate 190/Min.
The RP-period is 220 msec, 110 msec duration of the PR. The P waves are positive in leads II, III, aVF, V2, V3, V4. An electrical alternans can be detected.
Termination of the tachycardia after 12 mg adenosine iv Thereafter AV block II ° for 2 min, after which regular sinus rhythm.
The invasive electrophysiological study supports the hypothesis of an atrio-ventricular tachycardia on the floor of accessory pathway. The accessory pathway is located in the traditional nomenclature posteroseptalen segment. Shortest retrograde connection from the ventricle to the atrium in posteroseptalen segment (CS 9/10).
The catheter ablation with radiofrequency energy terminated the tachycardia. Retrograde conduction via the accessory leader is no longer detectable, tachycardia no longer inducible. The review is not a stress-related tachycardia. An arrhythmia is no longer detectable.
In the present case is a patient with a "hidden WPW" (Concealed-WPW).
The history of sudden onset of tachycardia and sudden end, respectively, of the influence of Valsalva maneuver for the termination of the tachycardia is a typical clinical signs of atrioventricular re-entry tachycardia. Atrio-ventricular tachycardia may be present on the floor of atrioventricular nodal re-entry tachycardia (AVNRT) or atrioventricular re-entry tachycardia (AVRT). AVRT tachycardia are common enough, referred to as WPW tachycardia. In the present case is noteworthy that in the resting ECG is no indication of an accessory pathway. The PQ duration is normal, a delta-wave is not apparent. The only reference in an atrioventricular tachycardia provides the tachycardia itself Fortunately, the tachycardia was inducible in the context of the exercise test. The frequency of the tachycardia is 190/Min. The retrograde P waves are detected by the chamber complex. Here, the RP-duration longer than the PR duration. The P waves are positive in leads II, III, aVF, V2 and V3, moreover there is an electrical alternans. From this it can be diagnosed as an atrioventricular tachycardia origin. In addition to an accessory pathway, a junctional tachycardia with a 1:1 antegrade conduction to the chamber would be conceivable. The clinical signs of the termination of tachycardia by Valsalva maneuver and adenosine, however, speak against the junctional tachycardia, as well as the inability of the tachycardia to akzelerieren. Therefore, as a mechanism that remains is the AVNRT or AVRT.
In AVNRT there would be a almost a slow tachycardia. The antegrade conduction via the fast pathway, retrograde slow on. In this case, the P would be negative in the said derivatives. The positive P-wave has supported a bypass of the AV node, and this may be due to the polarity of the P-wave only in posteroseptalen area.
This example demonstrates the importance of resting ECG for diagnosis rhythmological. Although the surface ECG is no evidence for a pre-excitation, it is an accessory pathway. The tachycardia is part of "concealed WPW." The typical polarity of the P-wave during the tachycardia suggests the localization of the accessory rail. Only when these paths is the positive polarity in leads II, III, aVF, V2 and V3. Ablation was performed quickly and without complications with radiofrequency energy.
The typical diagnostic localization of the accessory pathway is based on the polarity of the delta wave. Here is the relevant literature (MS Arruda et al., Journal Cardiovasc Electrophysiol 9/2-12, 1998) pointed out. The work of Arruda is recommended because it allows in simple terms because of the polarity of the delta wave, the localization of the accessory pathway. This is worth mentioning the derivatives that are of importance for this: I, II, V1, aVF. For the left lateral frequent trains such a questionable positive or negative delta wave in V1, a positive deflection in V1 and a positivity would be too demanding in aVF, to detect a left-lateral, left anterolateral position. At this negativity in aVF were then left in the posterior or posterolateral left. These schemes allow ECG, invasive electrophysiologic investigation brief, time-saving and less stressful durchzuführ patient.
Supraventricular tachycardia; to note that electrical alternans, retrograde P wave
Left: Intracardiac ECG: Earliest retrograde excitation in the coronary sinus (CS) CS beri 9/10. Ablation at this point eliminates the accessory rail.
Right: Intracardiac ECG: right ventricular pacing after ablation - no retrograde conductio
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