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Ventricular Tachycardia In A Patient With Myopathy

Submitted by Dawn on Tue, 12/19/2017 - 23:15

These two ECGs are from a 77-year-old woman who was complaining of palpitations and mild shortness of breath.  She stated a history of atrial fibrillation.  She was alert, with a systolic BP over 120.  At the hospital, she was found to have cardiomyopathy, resulting in global hypokinesis. She also had significant coronary artery narrowing in her left main, left anterior descending, and circumflex, which were treated with coronary artery bypass graft surgery.

The first ECG was taken on arrival of the EMS crew at the patient’s home.  It shows ventricular tachycardia, rate 226 bpm, All WCTs should be considered to be ventricular tachycardia until proven otherwise.  While WCT can sometimes be difficult to definitively diagnose in the field, this ECG has many features which favor the diagnosis of VT, including:

·         An extremely wide QRS (I measure .24 sec., the machine measures .368 sec.).

·         An extreme left axis deviation (aVF is all negative).

·         Absence of either RBBB or LBBB pattern, with a  completely negative QRS in V6.  This all negative V6 places the liklihood of the rhythm being VT to about 100%.

Dawn's picture

Right Ventricular Outflow Tract Tachycardia (RVOT)

Submitted by Dawn on Tue, 12/16/2014 - 00:00

This ECG was taken from a patient who was complaining of palpitations and tachycardia, but who was hemodynamically stable, with no history of heart disease.  It is an example of RIGHT VENTRICULAR OUTFLOW TRACT TACHYCARDIA, a type of idiopathic ventricular tachycardia.  The ECG signs of RVOT are:  wide QRS complex, left bundle branch block pattern (QRS negative in V1 and positive in Leads I and V6), heart rate over 100 bpm, rightward or inferior axis (LBBB usually has a normal to leftward axis), AV dissociation.

RVOT accounts for about 10% of all ventricular tachycardias, and 70% of idiopathic VT.  It is most often found in structurally normal hearts, but it may occur in patients with arrhythmogenic right ventricular dysplasia.  For more on RVOT, read Life In the Fast Lane.

RVOT tachycardia sometimes converts with adenosine.  The patient in this example converted after being administered amiodarone.

Dawn's picture

Wide Complex Tachycardia

Submitted by Dawn on Sat, 09/06/2014 - 15:03

Wide-QRS rhythms can be difficult to diagnose from the ECG alone.  This difficulty is compounded when the rate is fast, as it can be hard to determine if P waves are present before the QRSs, or dissociated, or absent.

This ECG and rhythm strip were donated to the ECG Guru by Ryan Cihowiak.  We don't have clinical information on the patient, unfortunately.  It is a great example, however, of how difficult WCT can be to diagnose.

In the 12-Lead ECG, we see wide QRS complexes that are regular at a rate of 131 / minute. There are no obvious P waves before the QRS complexes, and no obvious distortion of the T waves, which would suggest a "hidden" P wave.  Unfortunately, there is significant artifact, which makes searching for P waves difficult.  The pattern overall suggests left bundle branch block, with the negative QRS in Lead V1 and positive QRS complexes in Leads I and V6.  However, one requirement for the diagnosis of LBBB is a supraventricular rhythm, and P waves are the best indicator of that.  An irregularly-irregular rhythm, indicating atrial fib, would also have made LBBB more likely.  In typical LBBB, the frontal plane axis is usually left-normal or left.  In this ECG, Lead III is taller than Lead I, putting the axis within normal range, but slightly rightward.

The rhythm strip uncovers something else.  Possible P waves are seen in some of the ST segments (arrows).  Are these dissociated?  Do they represent a first-degree AV block?  Are they actually artifact?  If this is a supraventricular rhythm, there is LBBB.   Then, notice beats #7,8,9.  If this rhythm is supraventricular (with LBBB), those must be a salvo of V Tach.  But, one of the possible P waves occurs in front of beat #7.

Another possibility is Right Ventricular Outflow Tract Tachycardia.  RVOT is a type of V Tach that typically has a LBBB pattern, with a slightly rightward axis.  If this is the case, beats #7,8,9 are probably "capture" beats or "fusion" beats.  Capture and fusion beats "prove" that the underlying tachycardia is ventricular, since, by definition, capture and fusion represent a return to supraventricular control of the rhythm.

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