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Europace Advance Access originally published online on March 11, 2008
Europace 2008 10(4):509-510; doi:10.1093/europace/eun053
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

T WAVE ALTERNANS

Macroscopic T-wave alternans during non-sustained ventricular tachycardia

Piotr Kukla1, Marek Jastrzebski2,* and Leszek Bryniarski2

1 Department of Internal Medicine, Specialistic Hospital, Gorlice, Poland; 2 1st Department of Cardiology and Hypertension, College of Medicine, Jagiellonian University, ul. Kopernika 17, 31-501 Krakow, Poland

Manuscript submitted 31 December 2007. Accepted after revision 13 February 2008.

* Corresponding author. Tel: +48 124247301 or +48 124247322; fax: +48 124247320. E-mail address: mcjastrz{at}cyf-kr.edu.pl

Key Words: T-wave alternans, Torsade de pointes, Long QT, Cardiomyopathy

A 68-year-old female was admitted after syncope. Her ECG showed a sinus rhythm of 54 bpm with deep, negative T-waves in leads I, II, III, aVF, and V2–V6 with a prolonged QT interval (QTcV4 of 610 ms and QTcIII of 503 ms; Figure 1, upper trace). Bedside echocardiography revealed the presence of prominent left ventricular (LV) hypertrophy (diastolic interventricular septum thickness of 25 mm, diastolic posterior wall thickness of 11 mm, and apical thickness of 16 mm) and an LV ejection fraction of 60%. The patient did not take any medications that could impact the QT interval, and no electrolyte disturbances were observed. Therefore, a diagnosis of hypertrophic cardiomyopathy and long-QT syndrome was made. Continuous ECG monitoring revealed ventricular ectopic beats with episodes of non-sustained ventricular tachycardia (VT) during which alternation of positive and negative T-waves was present (Figure 1, lower trace, marked with asterisks). No T-wave alternas was observed during sinus rhythm.


Figure 1
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  		Figure 1 Initial ECG showed a sinus rhythm of 54 bpm with deep, negative T waves in leads I, II, III, aVF, and V2-V6 with a prolonged QT interval and marked QT dispersion. Continuous ECG monitoring in the ICU revealed ventricular ectopic beats and many episodes of nonsustained ventricular tachycardia (VT) during which alternation of positive and negative T waves was present (asterisks; lower trace).

 
Macroscopic T-wave alternans is sometimes observed during sinus rhythm in patients with a long QT interval and is considered a harbinger of torsade de pointes VT and sudden death. However, to the best of our knowledge, this is the first report of macroscopic T-wave alternans during VT episodes. Most likely in this case, with a marked QT prolongation and QT dispersion with superimposed severe LV hypertrophy, T-wave alternans is observed during VT because over a critical heart rate, the action potential duration of some cells prolongs when compared with that of other neighbouring cells.


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This Article
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