© 2004 by European Society of Cardiology
ISSUE ARRHYTHMIA
Spontaneous transition of four different types of supraventricular tachycardias in one patient
aThe Division of Cardiology, Department of Medicine, Mackay Memorial Hospital Taipei, Taiwan, ROC; bThe Division of Cardiology, Department of Medicine, National Yang-Ming University, School of Medicine, Veterans General Hospital-Taipei 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan, ROC
Manuscript submitted 24 July 2003. Accepted after revision 23 December 2003.
*Corresponding author. Tel.: +886-2-2875-7156; fax: +886-2-2873-5656. E-mail address: epsachen{at}ms41.hinet.net (S.-A. Chen).
A 47-year-old male patient was referred to this laboratory for treatment of frequent episodes of supraventricular tachycardia. He had hypotension with dizziness during tachycardia. The 12-lead ECG during sinus rhythm showed ventricular preexcitation.
During electrophysiological study, right atrial burst pacing induced atrial fibrillation with rapid ventricular rate through the accessory pathway. It was organized to atypical atrial flutter-like tachycardia with 2 to 1 atrioventricular conduction for several beats. (It showed positive F waves in leads II and V1, with irregular cycle length, and was likely either left-sided atrial flutter or a pulmonary vein tachycardia.) Then, two slow–fast atrioventricular nodal reentrant echo-like (AVNRE) beats with possibly retrograde concealed conduction in the left lateral accessory pathway were demonstrated. Finally, antegrade conduction was through the third intermediately conducting AV nodal pathway, the retrograde fast pathway was blocked, and a sustained orthodromic atrioventricular reciprocating tachycardia (AVRT) using the left lateral accessory pathway for retrograde conduction followed (Fig. 1). Alternatively, this intermediate rhythm (AVNR echo beats) was due to low atrial tachycardia beats with a delay in the AV node or via the slow pathway (long AH interval) and the first beat of AVRT was due to an atrial beat with a shorter AH interval or conducting through the fast pathway. The AVRT was confirmed by classical resetting criteria and ventricular pacing manoeuvre during tachycardia. Radiofrequency energy targeted at the left lateral aspect of mitral annulus successfully eliminated the accessory pathway. After successful ablation, antegrade dual AV nodal physiology with retrograde AV nodal conduction was demonstrated. This patient did not have recurrence of supraventricular tachycardia during one and a half-years of follow-up.
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Coexistence of double supraventricular tachycardias in one patient has been reported [1,
2], and novel mechanisms have been demonstrated in this laboratory [3]. However, coexistence of four different types of supraventricular arrhythmias with spontaneous transition in one patient is rare, and this phenomenon has not been reported in the literature. References
[1] Wellens HJJ, Atie J, Smeets JLRM, Cruz FES, Gorgels AP, Brugada P. The electrocardiogram in patients with multiple accessory atrioventricular pathways. J Am Coll Cardiol 1990; 16: 745–751.[Abstract]
[2] Wishner SH, Kastor JA, Yurchak PM. Double atrial and atrioventricular junctional tachycardia. N Engl J Med 1972; 287: 552–553.[Medline]
[3] Kuo JY, Tai CT, Chiang CE, et al. Mechanisms of transition between double paroxysmal supraventricular tachycardias. J Cardiovasc Electrophysiol 2001; 12: 1339–1345.[Medline]
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