Idiopathic Ventricular Tachycardia Associated With AV Reciprocating Tachycardia
Idiopathic Ventricular Tachycardia Associated With AV Reciprocating Tachycardia
Charles-Lwanga K. Bennin
Avinash Chandra
Case Report A forty-six year old female patient with a medical history of asthma and seasonal allergies presented with a two day history of shortness of breath, associated with palpitations. She denied chest pain or diaphoresis. Patient reported past history of similar complains that usually lasted less than two minutes and were relieved with aspirin. The longest episode of palpitations lasted approximately twenty minutes. Her social history was significant for tobacco and alcohol abuse, but negative for substance abuse. Her family history was significant for cardiovascular disease. Pertinent findings on physical examination were significant for elevated blood pressure at 156 mmHg/112 mmHg and tachycardia at 112 beats per minute. Her electrocardiogram (EKG) showed tachycardia at a rate of 150 beats per minute with a long RP interval concerning for atypical AV reciprocating tachycardia (AVRT). The EKG also revealed right bundle branch block with a left axis deviation (Figure 1) and non-sustained ventricular tachycardia (Figure 2) indicating a diagnosis of idiopathic ventricular tachycardia. A urine drug screen was positive for cocaine.
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deviation configuration; and the rare presentation of upper
septal fascicular ventricular tachycardia with a narrow QRS and
normal axis configuration.6
Nogami also classified idiopathic ventricular tachycardia into
adenosine sensitive, propranolol sensitive and
verapamilsensitive fascicular ventricular tachycardia.9 It appears that
fascicular ventricular tachycardia are sensitive to
phenylalkylamine class L-Type calcium channel blockers such
as verapamil as have been well described by Belhassen.10,11
Calcium channel blockers also suppress conduction through
atrio-ventricular (AV) node, and are effective on both AV
reciprocating tachycardia (AVRT) and AV nodal reentrant
tachycardia (AVNRT).
Atrial pacing as well as supraventricular tachycardia has been
shown to induce ventricular tachycardia due to either reentry or
triggered automaticity. It is not uncommon to find co-existing
tachyarrhythmia and a few cases have been reported of
ventricular tachycardia initiated by atrial arrhythmias including
AV reciprocating tachycardia also known as AV reentrant
tachycardia (AVRT).5
Literature search using PubMed with the following keywords
“Idiopathic ventricular tachycardia, AV reentrant tachycardia,
AV reciprocating tachycardia, AVRT” produced 2 articles. One
case series reported seven patients without structural heart
disease in which AVNRT spontaneously triggered VT in three
cases.12 Another case report illustrated a patient with
WolffParkinson-White (WPW) syndrome. Ventricular tachycardia
originating from the right ventricular outflow tract was induced
during isoprenaline infusion. This also led to atrioventricular
reentrant tachycardia (AVRT). This case report was significant
in that the ventricular tachycardia was possibly driven by
catecholamine stimulation13.
In our case report we present a patient with possible cocaine
induced idiopathic ventricular tachycardia and AV reentrant
tachycardia. Cocaine works on by increasing release of
norepinephrine and dopamine and blocking reabsorption of
norepinephrine, dopamine and serotonin. Cocaine also blocks sodium
channels, thereby interfering with the propagation of action
potentials. The release of catecholamines that occur in cocaine
intake may exacerbate changes in the action potential threshold
and hence stimulate automaticity. Management of idiopathic
ventricular tachycardia includes radiofrequency ablation and
intravenous verapamil.
1. Cohen HC , Gozo EG Jr, AP. Ventricular tachycardia with narrow QRS complexes (left posterior fascicular tachycardia) . Circulation . 1972 ; 45 ( 5 ): 1035 - 1043 .
2. Zipes DP , Foster PR , Troup PJ , DH. P. Atrial induction of ventricular tachycardia: reentry versus triggered automaticity . Am J Cardiol . 1976 ; 44 ( 1 ): 1 - 8 .
3. Cho YK , Han SW , Kim YN . Cases of familial idiopathic left ventricular tachycardia . Europace . 2007 ; 9 ( 9 ): 852 - 853 .
4. Topilski I , Glick A , Belhassen B . Idiopathic left ventricular tachycardia with a right bundle branch block morphology and left axis deviation (“Belhassen type”): results of radiofrequency ablation in 18 patients . Isr Med Assoc J. 2004 ; 6 ( 4 ): 195 - 200 .
5. Ichiro Watanabe , Satoshi Kunimoto, Kazuhiko Kondo, Toshiaki Kojima, Toshiko Nakai, Atsushi Shindo, Naohiro Oshikawa, Satoshi Saito, Yukio Ozawa, Kanmatsuse K. Radiofrequency Catheter Ablation of Coexistent Atrioventricular Reciprocating Tachycardia and Left Ventricular Tachycardia Originating in the Left Anterior Fascicle . Jpn Circ J 1999 ; 63 : 223 - 227 .
Kuo JY , Tai CT , Chiang CE , Yu WC , Huang JL , Hsieh MH , Hou CJ , Tsai CH , Ding YA , SA. C. Is the fascicle of left bundle branch involved in the reentrant circuit of verapamil-sensitive idiopathic (...truncated)