In this article, the authors describe a case involving two different wide complex tachycardias. The authors also highlight the importance of a thorough electrophysiological evaluation when evaluating a wide complex tachycardia in a young patient.

Case Report

A 38-year-old Caucasian male presented to the emergency room with rapid palpitations and was noted to be in wide QRS tachycardia at 216 beats per minute. The tachycardia terminated with intravenous adenosine. Review of the electrocardiogram showed a typical left bundle branch block (LBBB) pattern with QRS duration of 160 msec and no clearly discernible P waves (Figure 1). A 12-lead electrocardiogram following tachycardia termination showed normal sinus rhythm with no evidence of preexcitation.

In this artcle, the authors present a case that illustrates the importance of keeping an open mind while evaluating SVTs.

Case Presentation

A 53-year-old morbidly obese Caucasian female with past medical history of paroxysmal palpitations, hypertension, diastolic heart failure, and chronic bronchitis was admitted for pneumonia and respiratory failure. She initially had to be mechanically ventilated, and was subsequently extubated. Post-extubation, she was noted to have multiple episodes of narrow complex tachycardia (Figure 1), resulting in hypotension, chest discomfort, and shortness of breath.

In another installment of EP Lab Digest’s EP 101 series, the authors present three new case overviews, then ask readers to test their knowledge in EP by answering questions about each case.

Case #1:

A 27-year-old female underwent electrophysiology (EP) study for symptomatic palpitations. During the EP study, a single high right atrial premature extrastimulus (S1S2 coupling interval = 300 msec) following a 400 msec drive train demonstrated a “jump” in the AV nodal function curve and initiated a narrow complex tachycardia.

In this article, the authors provide Part 2 of a wide complex tachycardia case study (Part 1 was published in EP Lab Digest’s November 2008 issue).

Case Presentation

A 53-year-old man with coronary artery disease (s/p stent placement in 2001) presented to the emergency room with chest pain radiating to the jaw associated with palpitations, dyspnea and diaphoresis. An electrocardiogram showed a wide complex tachycardia at 190 bpm with a left bundle branch block (LBBB) morphology and normal QRS axis (Figure 1). Blood pressure was 139/60 mmHg.

Ventricular tachycardia was presumed and lidocaine 100 mg IV was given, which terminated the tachycardia and symptoms. A subsequent ECG showed sinus rhythm with a narrow QRS, normal intervals, and inferior Q-waves.

History

In their 1930 case series and three-lead EKG analysis of 11 healthy patients with a propensity for paroxysmal tachycardia, Drs. Wolff, Parkinson, and White described most of the phenomena associated with the condition that now bears their name.¹ Specifically, they observed short PR intervals with bundle branch block aberrancy that normalized with exercise or parasympathetic inhibition, all in patients that had little other organic heart disease. In an unfortunate subset of the patients exhibiting these phenomena, symptoms had lasted for decades.