Idiopathic Ventricular Tachycardia Associated With AV Reciprocating Tachycardia

The Medicine Forum, Dec 2009

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.

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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. - 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)


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Charles-Lwanga K. MD Bennin, Avinash MD Chandra. Idiopathic Ventricular Tachycardia Associated With AV Reciprocating Tachycardia, The Medicine Forum, 2009, pp. 23, Volume 11, Issue 1,