Differentiating Wide Complex Tachycardiastatic.livemedia.gr/.../us6_20121204092817_wideqrsgood.pdfWide Complex Tachycardias (WCT) -QRS duration > 120 ms and heart rate > 100 beats/miin

Differentiating WideDifferentiating Wide

Complex TachycardiaComplex Tachycardia

MANOLATOS DIMITRIOS M.DMANOLATOS DIMITRIOS M.D

DefinitionsDefinitions

CausesCauses

Electrocardiographic featuresElectrocardiographic features

Diagnostic CriteriaDiagnostic Criteria

Wide Complex Tachycardias Wide Complex Tachycardias (WCT)(WCT) --QRSQRS

duration > 120 ms and heart rate > 100duration > 120 ms and heart rate > 100

beats/miinbeats/miin

Ventricular Tachycardia Ventricular Tachycardia (VT)(VT) -- 3 or more3 or more

consecutive ventricular beats with a rate of 100consecutive ventricular beats with a rate of 100

beats/min or morebeats/min or more

Nonsustained VT Nonsustained VT (NSVT)(NSVT) –– tachycardia < 30tachycardia < 30

seconds durationseconds duration

Sustained VT:Sustained VT: Last > 30 secondsLast > 30 seconds

Causes significant hemodynamic symptomsCauses significant hemodynamic symptoms

Requires therapeutic intervention for terminationRequires therapeutic intervention for termination

Monomorphic VT Monomorphic VT –– uniform and stable QRSuniform and stable QRSappearance in any given leadappearance in any given lead

Polymorphic VT Polymorphic VT –– continuouslly varying QRScontinuouslly varying QRSmorphology and/or axis in a single lead duringmorphology and/or axis in a single lead during an episodean episode

SupraventricularSupraventricular tachycardia tachycardia (SVT)(SVT) –– any tachycardia any tachycardia using the normal AV conduction system for ventricularusing the normal AV conduction system for ventricularexcitation, w/ the tachycardia originating in the atria excitation, w/ the tachycardia originating in the atria oror the AV node and requiring the AV node for itsthe AV node and requiring the AV node for itsmaintenancemaintenance

Aberrant conduction (aberrancy) Aberrant conduction (aberrancy) –– conduction delay conduction delay or block in the Hisor block in the His--Purkinje system during Purkinje system during antegradeantegradeconduction of impulses over the normal AVconduction of impulses over the normal AV--conduction conduction system resulting in a wide, abnormal QRSsystem resulting in a wide, abnormal QRS

PrePre--excitation syndrome excitation syndrome –– AV conduction can occur via the normal AV conduction can occur via the normal conduction system and via an accessory AV pathwayconduction system and via an accessory AV pathway

The two pathways create tthe substrate for a reentrant circuit,The two pathways create tthe substrate for a reentrant circuit,facillittating AV reentrant tachycardia (AVRT)facillittating AV reentrant tachycardia (AVRT)

Orthodromic AVRT Orthodromic AVRT –– antegrade conduction over the AV node and antegrade conduction over the AV node and retrograde conduction via the accessory pathway; QRS is narrow retrograde conduction via the accessory pathway; QRS is narrow unless there is aberrant conductionunless there is aberrant conduction

Antidromic AVRT Antidromic AVRT –– antegrade conduction over the accessory antegrade conduction over the accessory pathway and retrograde conduction over the AV node or a second pathway and retrograde conduction over the AV node or a second accessory pathway; QRS is wideaccessory pathway; QRS is wide

PrePre--excited tachycardias excited tachycardias –– ventricular activation occurs ventricular activation occurs predominately or exclusively via an accessory pathwaypredominately or exclusively via an accessory pathway

VT VT -- most common cause of WCT (80% of cases inmost common cause of WCT (80% of cases inunselected populations and more than 95% in pts w/unselected populations and more than 95% in pts w/structural heart diseasestructural heart disease

Can originate anywhere below the AV node: His bundle,,Can originate anywhere below the AV node: His bundle,,bundllebundlle branches,, fascicles,, Purkinje fibers,, and ventricular branches,, fascicles,, Purkinje fibers,, and ventricular

myocardial tissuemyocardial tissue

Fixed conduction block Fixed conduction block –– when there is a baselinewhen there is a baselineblock during sinus rhythm due to pathological lesionsblock during sinus rhythm due to pathological lesions in the in the conduction systemconduction system

Seen as baseline left bundle branch block (LBBB),, rightSeen as baseline left bundle branch block (LBBB),, right bundle bundle branch block (RBBB),, or a nonspecificbranch block (RBBB),, or a nonspecific intraventricularintraventricular conduction conduction delay (IVCD)delay (IVCD)

OrthodromicOrthodromic AVRT w/ aberrancyAVRT w/ aberrancy

PrePre--excitation excitation tachycardiastachycardias

AntidromicAntidromic AVRTAVRT

Relatively uncommon, occurring in about 6% of casesRelatively uncommon, occurring in about 6% of cases

Difficult to differentiate from VT because ventricular Difficult to differentiate from VT because ventricular activation begins outside the normal activation begins outside the normal intraventricularintraventricularconduction system in bothconduction system in both

Atrial fibrillation with an accessory pathwayAtrial fibrillation with an accessory pathway

Tachycardia'sTachycardia's w/ two accessory pathwaysw/ two accessory pathways

Pacemakers and cardiac resynchronization therapyPacemakers and cardiac resynchronization therapy

ElectrocardiogramsElectrocardiograms

Rate:Rate: limited use in distinguishing VT from SVT aslimited use in distinguishing VT from SVT asthere is too much overlapthere is too much overlap

Consider Atrial flutter when Consider Atrial flutter when HR HR is ~150 beats/minis ~150 beats/min

Regularity:Regularity: VT is generally regular, though there can beVT is generally regular, though there can beslight variation in the RR intervalsslight variation in the RR intervals

Slight irregularity at the onset (Slight irregularity at the onset (““warmwarm----up up phenomenonphenomenon””))--favors VTfavors VT

Grossly irregular WCT likely represents:Grossly irregular WCT likely represents:1) AF w/ aberrant conduction,1) AF w/ aberrant conduction,2) AF w/ conduction over an accessory pathway,,2) AF w/ conduction over an accessory pathway,,3) polymorphic VT3) polymorphic VT

Uniformity of the RR intervals' favors SVTUniformity of the RR intervals' favors SVT

Axis:Axis: mean QRS axis in the normal range favors SVTw/ mean QRS axis in the normal range favors SVTw/ aberrationaberration

Right superior axis of Right superior axis of --90 to 90 to ±± 180180°° strongly suggests strongly suggests VT(sometimes called VT(sometimes called ““northwestnorthwest”” or extreme right axis)or extreme right axis)

Should compare the axis during SR,, an axis shift during Should compare the axis during SR,, an axis shift during WCT of > 40WCT of > 40°° favors VTfavors VT

In RBBBIn RBBB--like WCT, axis to the left of like WCT, axis to the left of --3030°° suggest VTsuggest VT

In LBBBIn LBBB--like WCT,axis to the right of +90like WCT,axis to the right of +90°° suggests VTsuggests VT

QRS duration: generally, a wider QRS favors QRS duration: generally, a wider QRS favors VTVT

In RBBBIn RBBB----like WCT,, duration > 140 msec suggests like WCT,, duration > 140 msec suggests VTVT

In LBBBIn LBBB----like WCT,, duration > 160 msec suggest like WCT,, duration > 160 msec suggest VTVT

QRS duration > 160 msec is a strong predictor of QRS duration > 160 msec is a strong predictor of VTVT regardlessregardlessof bundleof bundle----branch block morphologybranch block morphology

Except in cases of SVT w/ an AV accessory pathway and the Except in cases of SVT w/ an AV accessory pathway and the presence of drugs capable of slowing presence of drugs capable of slowing intraventricularintraventricular conductionconduction

Such as class 1A or class 1C agents or amiodaroneSuch as class 1A or class 1C agents or amiodarone

QRS duration < 140 msec does not QRS duration < 140 msec does not exclude VTexclude VT

VT originating from the septum or w/in the HisVT originating from the septum or w/in the His--Purkinje systemPurkinje system

Concordance: present when QRS complexes in all 6Concordance: present when QRS complexes in all 6precordialprecordial leads (V1leads (V1--V6) are V6) are monophasicmonophasic w/ the w/ the same polarity same polarity (90% specificity for VT)(90% specificity for VT)

Positive concordance Positive concordance –– All entirely positive w/All entirely positive w/totally,monophonictotally,monophonic R wavesR waves

Most often due to VT but can also occur in rare casesMost often due to VT but can also occur in rare casesof of antidromicantidromic AVRT w/ a left posterior accessory AVRT w/ a left posterior accessory

pathwaypathway Negative concordance Negative concordance ---- All entirely negative w/ deepAll entirely negative w/ deepmonophonic QS complexesmonophonic QS complexes

Concordance is not present if any of the 6 leads has aConcordance is not present if any of the 6 leads has abiphasic QRS (biphasic QRS (qRqR or RS complexes)or RS complexes)

Absence of concordance is Absence of concordance is not not diagnostically helpfuldiagnostically helpful

AV dissociation:AV dissociation: atrial activity that is independent of atrial activity that is independent of ventricular activity occurs in 20ventricular activity occurs in 20--50% off VT and almost 50% off VT and almost never in SVTnever in SVT

When the atrial rate is slower than the ventricular rate, When the atrial rate is slower than the ventricular rate, this strongly suggest VTthis strongly suggest VT

Atrial rate faster than the ventricular rate suggests a SVT, Atrial rate faster than the ventricular rate suggests a SVT, such as atrial flutter or AT w/ 2:1 AV conductionsuch as atrial flutter or AT w/ 2:1 AV conduction

There is a consistent relationship between the P waves There is a consistent relationship between the P waves and the QRS complexesand the QRS complexes

Presence of this largely establishes the Presence of this largely establishes the

diagnosis of VT but its absence is not diagnosis of VT but its absence is not

helpfulhelpful

May sometimes not be evident on ECGMay sometimes not be evident on ECG

Some cases of VT, the ventricular Some cases of VT, the ventricular

impulses conduct retrograde through the impulses conduct retrograde through the

AV node and capture the atrium, AV node and capture the atrium,

preventing dissociationpreventing dissociation

Echo beatEcho beat –– VT impulse conducted retrogradely VT impulse conducted retrogradely through the AV node to produce atrial capture that, on through the AV node to produce atrial capture that, on to the ventricles, produces a narrow QRS complexto the ventricles, produces a narrow QRS complex

Fusion beatFusion beat –– when one impulse originating from the when one impulse originating from the ventricle and a second supraventricular impulse ventricle and a second supraventricular impulse simultaneously activate the ventricular myocardiumsimultaneously activate the ventricular myocardium

Morphology is intermediate between that of a sinus Morphology is intermediate between that of a sinus beat and a purely ventricular complexbeat and a purely ventricular complex

Capture beatCapture beat –– normal conduction momentarily normal conduction momentarily ““capturedcaptured”” control of ventricular activation from the control of ventricular activation from the VT focusVT focus

QRS Morphology:QRS Morphology:

most approaches involve classifying the most approaches involve classifying the

WCT as having RBBBWCT as having RBBB——like pattern or like pattern or

LBBBLBBB----like patternlike pattern

RBBBRBBB--like pattern: QRS polarity is positive like pattern: QRS polarity is positive

in leads V1 and V2in leads V1 and V2

LBBBLBBB--like pattern: QRS polarity is like pattern: QRS polarity is

negative in leads V1 and V2negative in leads V1 and V2

RBBB pattern associations:RBBB pattern associations: Lead V1: Lead V1: monophasicmonophasic R or biphasic R or biphasic qRqR complexcomplexfavors VTfavors VT

TriphasicTriphasic RSRRSR’’’’ or or RsRRsR’’’’ complex (complex (““rabbitrabbit----earear””signsign) favors SVT,, except if the left peak of the ) favors SVT,, except if the left peak of the RsRRsR’’’’ complex is taller than the right peakcomplex is taller than the right peak

Lead V6: Lead V6: rSrS complex (R wave smaller than S complex (R wave smaller than S wave) favors VT wave) favors VT

RsRs (R wave larger than S wave) complex favors (R wave larger than S wave) complex favors SVTSVT

LBBB pattern associations:LBBB pattern associations:

Lead V1 or V2:: broad initial R wave of >30 msec duration favorLead V1 or V2:: broad initial R wave of >30 msec duration favors VTs VT

Slurred or notched downstroke of the S wave favors VTSlurred or notched downstroke of the S wave favors VT

Duration from the onset of the QRS complex to the nadir of the Duration from the onset of the QRS complex to the nadir of the QS or QS or S wave of M 60 msec favors VTS wave of M 60 msec favors VT

Absence of an initial R wave or a small initial R wave of < 30 Absence of an initial R wave or a small initial R wave of < 30 msec msec favors SVTfavors SVT

A swift, smooth downstroke of the S wave in w/ a duration of < A swift, smooth downstroke of the S wave in w/ a duration of < 60 60 msec favors SVTmsec favors SVT

Lead V6: any Q or QS wave favors VTLead V6: any Q or QS wave favors VT

Absence of a Q wave favors SVTAbsence of a Q wave favors SVT

Brugada CriteriaBrugada Criteria

Stepwise approach in which four criteria for VT Stepwise approach in which four criteria for VT are sequentially evaluated and if any are are sequentially evaluated and if any are satisfied,thesatisfied,the diagnosis off VT is made; diagnosis off VT is made;

if none are fulfilled then diagnosis off SVT is if none are fulfilled then diagnosis off SVT is made by exclusionmade by exclusion

1)Lead V11)Lead V1--V6 are inspected for an RS complex, V6 are inspected for an RS complex, if none than concordance is presentif none than concordance is present

2)If an RS complex is present, the longest 2)If an RS complex is present, the longest interval in any lead between the onset of the R interval in any lead between the onset of the R wave and the nadir of the S wave (RS interval) wave and the nadir of the S wave (RS interval) is measured VT if the RS interval is > 100 msecis measured VT if the RS interval is > 100 msec

3)If the RS interval is < 100 msec, then 3)If the RS interval is < 100 msec, then evaluate for the presence of AV evaluate for the presence of AV dissociation to diagnose VTdissociation to diagnose VT

4)If the RS interval is < 100 msec and AV 4)If the RS interval is < 100 msec and AV dissociation is not evident, then evaluate dissociation is not evident, then evaluate the QRS morphology for V1the QRS morphology for V1--positive and positive and V1V1--negative WCTnegative WCT

If either the V1If either the V1--V2 or the V6 criteria are V2 or the V6 criteria are not consistent w/ VT, then SVT is not consistent w/ VT, then SVT is assumedassumed

New New aVRaVR AlgorithmAlgorithm

Hypothesized reasons for using Hypothesized reasons for using aVRaVR::

During SVT w/ BBB,, the initial During SVT w/ BBB,, the initial septalseptal activation and the latter activation and the latter main ventricular activation waterfront move away from lead main ventricular activation waterfront move away from lead aVRaVR,, creating a negative QRS complex in lead ,, creating a negative QRS complex in lead aVRaVR

Exception to this generalization is occurs in inferior Exception to this generalization is occurs in inferior myocardial infarction where there is the loss of the initial myocardial infarction where there is the loss of the initial inferiorly directed forces creating an initial r wave (inferiorly directed forces creating an initial r wave (rSrScomplex) during NSR or SVTcomplex) during NSR or SVT

Because an initial dominant R wave in Because an initial dominant R wave in aVRaVR is incompatible w/ is incompatible w/ SVT,, its presence suggest VT,, SVT,, its presence suggest VT,, typiicallytypiically originating from the originating from the inferior or apical regioninferior or apical region

Useful for detecting VT originating from sites other Useful for detecting VT originating from sites other than the inferior or apical wall, but would not show an than the inferior or apical wall, but would not show an initial R wave in aVRinitial R wave in aVR

Would rather show a slow,, initial upward vector of Would rather show a slow,, initial upward vector of variable size pointing toward aVR even if the main variable size pointing toward aVR even if the main vector of the VT points downward and creates a vector of the VT points downward and creates a predominately negative QRS in lead aVRpredominately negative QRS in lead aVR

Exceptions would be VT originating from theExceptions would be VT originating from the

most basal sites of the interventricular septum or free most basal sites of the interventricular septum or free wallwall

Stepwise approach similar to the Brugada Stepwise approach similar to the Brugada

criteriacriteria

used to analyze monophonic WCT:used to analyze monophonic WCT:

1) Evaluate for the presence of an initial R 1) Evaluate for the presence of an initial R

wavewave

2) Evaluate for the presence of an initial r or 2) Evaluate for the presence of an initial r or

q wave with width M 40 msecq wave with width M 40 msec

3)Evaluate for notching on the descending 3)Evaluate for notching on the descending

limb of a negative onset, predominately limb of a negative onset, predominately

negative QRS complexnegative QRS complex

We analyzed the RWPT at lead II, defined as the duration of the QRS from the initiation ofdepolarization until the first change of the polarity, independent of whether theQRS deflection was positive or negative.

A R-wave peak time ≥ 50 ms at DII is a simple and highly sensitive criterion that discriminates VT from SVT in patients with wide QRS complextachycardias.

lead II algorithmlead II algorithm

Pava LF, et al. Heart Rhythm 2010;7:922–6.

ECG criteria for epicardial VTECG criteria for epicardial VT

Case 1Case 1Case 1Case 1Case 1Case 1Case 1Case 1

65 yo65 yo65 yo65 yo65 yo65 yo65 yo65 yo

CAD (anterior MI), LVEF: 35%, NYHA ICAD (anterior MI), LVEF: 35%, NYHA ICAD (anterior MI), LVEF: 35%, NYHA ICAD (anterior MI), LVEF: 35%, NYHA ICAD (anterior MI), LVEF: 35%, NYHA ICAD (anterior MI), LVEF: 35%, NYHA ICAD (anterior MI), LVEF: 35%, NYHA ICAD (anterior MI), LVEF: 35%, NYHA I

bb, ACE, spironolactone, amiodaronebb, ACE, spironolactone, amiodaronebb, ACE, spironolactone, amiodaronebb, ACE, spironolactone, amiodaronebb, ACE, spironolactone, amiodaronebb, ACE, spironolactone, amiodaronebb, ACE, spironolactone, amiodaronebb, ACE, spironolactone, amiodarone

incessant wide QRS tachycardiaincessant wide QRS tachycardiaincessant wide QRS tachycardiaincessant wide QRS tachycardiaincessant wide QRS tachycardiaincessant wide QRS tachycardiaincessant wide QRS tachycardiaincessant wide QRS tachycardia



1.1.1.1.1.1.1.1. VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)

2.2.2.2.2.2.2.2. SVT with aberrationSVT with aberrationSVT with aberrationSVT with aberrationSVT with aberrationSVT with aberrationSVT with aberrationSVT with aberration

3.3.3.3.3.3.3.3. VT right ventricular origin (apex)VT right ventricular origin (apex)VT right ventricular origin (apex)VT right ventricular origin (apex)VT right ventricular origin (apex)VT right ventricular origin (apex)VT right ventricular origin (apex)VT right ventricular origin (apex)

4.4.4.4.4.4.4.4. Antidromic SVT via an APAntidromic SVT via an APAntidromic SVT via an APAntidromic SVT via an APAntidromic SVT via an APAntidromic SVT via an APAntidromic SVT via an APAntidromic SVT via an AP

midmidmidmidmidmidmidmid--------diastolic potentialsdiastolic potentialsdiastolic potentialsdiastolic potentialsdiastolic potentialsdiastolic potentialsdiastolic potentialsdiastolic potentials

Case 2Case 2Case 2Case 2

60 yo man60 yo man60 yo man60 yo man

prior inferior MIprior inferior MIprior inferior MIprior inferior MI

LVEF: 45%LVEF: 45%LVEF: 45%LVEF: 45%



1.1.1.1.1.1.1.1. VT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular origin


3.3.3.3.3.3.3.3. VT right ventricular originVT right ventricular originVT right ventricular originVT right ventricular originVT right ventricular originVT right ventricular originVT right ventricular originVT right ventricular origin


Case 2, activation mappingCase 2, activation mappingCase 2, activation mappingCase 2, activation mapping


17 yo female17 yo female17 yo female17 yo female

ECG during SR: unremarkable ECG during SR: unremarkable ECG during SR: unremarkable ECG during SR: unremarkable

Transthoracic echocardiography: normal LV and Transthoracic echocardiography: normal LV and Transthoracic echocardiography: normal LV and Transthoracic echocardiography: normal LV and

RV RV RV RV



1.1.1.1.1.1.1.1. RVOT VTRVOT VTRVOT VTRVOT VTRVOT VTRVOT VTRVOT VTRVOT VT


3.3.3.3.3.3.3.3. LVOT VTLVOT VTLVOT VTLVOT VTLVOT VTLVOT VTLVOT VTLVOT VT

4.4.4.4.4.4.4.4. Idiopathic left fascicular VTIdiopathic left fascicular VTIdiopathic left fascicular VTIdiopathic left fascicular VTIdiopathic left fascicular VTIdiopathic left fascicular VTIdiopathic left fascicular VTIdiopathic left fascicular VT



Syncope during exercise Syncope during exercise Syncope during exercise Syncope during exercise

ECG during SR: negative T waves V1ECG during SR: negative T waves V1ECG during SR: negative T waves V1ECG during SR: negative T waves V1----3333

Transthoracic echocardiography: RV dilationTransthoracic echocardiography: RV dilationTransthoracic echocardiography: RV dilationTransthoracic echocardiography: RV dilation




2.2.2.2.2.2.2.2. RVOT VT due to ARVCRVOT VT due to ARVCRVOT VT due to ARVCRVOT VT due to ARVCRVOT VT due to ARVCRVOT VT due to ARVCRVOT VT due to ARVCRVOT VT due to ARVC

3.3.3.3.3.3.3.3. Epicardial VT due to ARVCEpicardial VT due to ARVCEpicardial VT due to ARVCEpicardial VT due to ARVCEpicardial VT due to ARVCEpicardial VT due to ARVCEpicardial VT due to ARVCEpicardial VT due to ARVC

4.4.4.4.4.4.4.4. Mitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VT



ECG during SR: unremarkableECG during SR: unremarkableECG during SR: unremarkableECG during SR: unremarkable

Holter monitoring: sustained tachycardiaHolter monitoring: sustained tachycardiaHolter monitoring: sustained tachycardiaHolter monitoring: sustained tachycardia

Verapamil terminates the tachycardiaVerapamil terminates the tachycardiaVerapamil terminates the tachycardiaVerapamil terminates the tachycardia



1.1.1.1.1.1.1.1. Mitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VTMitral annulus VT


3.3.3.3.3.3.3.3. LVOT VTLVOT VTLVOT VTLVOT VTLVOT VTLVOT VTLVOT VTLVOT VT


presystolic potentialpresystolic potentialpresystolic potentialpresystolic potentialpresystolic potentialpresystolic potentialpresystolic potentialpresystolic potential




•• 67 yo67 yo67 yo67 yo67 yo67 yo67 yo67 yo

•• no structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart disease

•• Transthoracic echocardiography and coronary Transthoracic echocardiography and coronary Transthoracic echocardiography and coronary Transthoracic echocardiography and coronary

angiography ruled out structural heart diseaseangiography ruled out structural heart diseaseangiography ruled out structural heart diseaseangiography ruled out structural heart disease

• MRI was normalMRI was normalMRI was normalMRI was normal

•• referred to our hospital for EPS/ablationreferred to our hospital for EPS/ablationreferred to our hospital for EPS/ablationreferred to our hospital for EPS/ablationreferred to our hospital for EPS/ablationreferred to our hospital for EPS/ablationreferred to our hospital for EPS/ablationreferred to our hospital for EPS/ablation



1.1.1.1.1.1.1.1. VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)VT left ventricular origin (apex)




pace mappingpace mappingpace mappingpace mapping

11111111----12 of 12 leads12 of 12 leads12 of 12 leads12 of 12 leads


propagation mappropagation mappropagation mappropagation map voltage mapvoltage mapvoltage mapvoltage map



•• 41 yo41 yo41 yo41 yo41 yo41 yo41 yo41 yo

•• no structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart diseaseno structural heart disease

•• Transthoracic echocardiography and exercise test Transthoracic echocardiography and exercise test Transthoracic echocardiography and exercise test Transthoracic echocardiography and exercise test

ruled out structural heart disease.ruled out structural heart disease.ruled out structural heart disease.ruled out structural heart disease.

•• Referred to our hospital for EPS/ablationReferred to our hospital for EPS/ablationReferred to our hospital for EPS/ablationReferred to our hospital for EPS/ablationReferred to our hospital for EPS/ablationReferred to our hospital for EPS/ablationReferred to our hospital for EPS/ablationReferred to our hospital for EPS/ablation



1.1.1.1.1.1.1.1. VT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular originVT left ventricular origin



4.4.4.4.4.4.4.4. Antidromic SVT via an AP (Mahaim fiber)Antidromic SVT via an AP (Mahaim fiber)Antidromic SVT via an AP (Mahaim fiber)Antidromic SVT via an AP (Mahaim fiber)Antidromic SVT via an AP (Mahaim fiber)Antidromic SVT via an AP (Mahaim fiber)Antidromic SVT via an AP (Mahaim fiber)Antidromic SVT via an AP (Mahaim fiber)

ΣΑΣΣΑΣ ΕΥΧΑΡΙΣΤΩΕΥΧΑΡΙΣΤΩ

Documents

Differentiating Wide Complex Tachycardiastatic.livemedia.gr/.../us6_20121204092817_wideqrsgood.pdfWide Complex Tachycardias (WCT) -QRS duration > 120 ms and heart rate > 100 beats/miin