Irregular Complex Tachycardia

HomeCirculationVol. 143, No. 11Irregular Complex Tachycardia Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBIrregular Complex TachycardiaNot Dual Atrioventricular Nodal Nonreentrant Tachycardia Ding Peng, MD, Xiaojian Liu, MD and Yangyang Pan, BSN Ding PengDing Peng Ding Peng, MD, Department of Cardiology, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People’s Hospital, B24 Yinquan South Rd, Qingyuan 511518, Guang Dong Province, People’s Republic of China. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8265-1808 Department of Cardiology, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People’s Hospital, People’s Republic of China. Search for more papers by this author , Xiaojian LiuXiaojian Liu Department of Cardiology, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People’s Hospital, People’s Republic of China. Search for more papers by this author and Yangyang PanYangyang Pan Department of Cardiology, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People’s Hospital, People’s Republic of China. Search for more papers by this author Originally published15 Mar 2021https://doi.org/10.1161/CIRCULATIONAHA.120.052913Circulation. 2021;143:1173–1176ECG ChallengeA 47-year-old man presented with a 2-year history of recurrent palpitations. The ECG (Figure 1) of a palpitation attack showed irregular complex tachycardia (180 bpm). Before admission, pharmacological therapy with metoprolol had failed to alleviate his symptoms. Twenty-four–hour Holter monitoring (Figure 2) was performed. What is the rhythm shown in Figures 1 and 2?Download figureDownload PowerPointFigure 1. A 12-lead ECG obtained during palpitation episodes.Download figureDownload PowerPointFigure 2. Holter monitor recording.Please turn the page to read the diagnosis.Response to ECG ChallengeECG (Figure 3) revealed irregular complex tachycardia with alternating narrow and wide QRS complexes. Typically, analysis of a complex ECG most importantly looks carefully at the presence of P waves and analyzes their relation to the QRS complexes.Download figureDownload PowerPointFigure 3. Annotated 12-lead ECG. The P wave was positive in lead II and negative in aVR, consistent with a sinus rhythm of 58 bpm. The front 8 sinus beats (blue stars) are simultaneously conducted through the anterograde fast, intermediate, and slow atrioventricular nodal pathways, producing triple ventricular response. Because the middle or slow pathway is in a refractory period, the last 2 sinus beats (red stars) are conducted only via the other 2 pathways, resulting in a dual ventricular response in different combinations. Stars indicate the P waves (Note that the PP intervals are regular). Black, red, and blue oblique arrows (in the atrioventricular portion of the ladder diagram) indicate conduction via the fast, intermediate, and slow pathways, respectively.The presence of regular sinus rhythm (58 bpm) with no other apparent atrial activity excludes atrial fibrillation and multifocal atrial tachycardia. Each P wave is followed by 3 QRS complexes, with a relatively constant coupling interval between the 3 QRS waves. For this regular 1:3 group beating pattern exhibited by the ECG, differential diagnoses include premature ventricular contraction, junctional extrasystole with retrograde block, and triple ventricular response. The presence of wide QRS beats is variable; some of the triple beats are all narrow, thus excluding premature ventricular contraction. We are left with 2 possible diagnoses: junctional extrasystole with retrograde block and triple ventricular response.Holter monitor recording provides important information for diagnosis. It shows 3 different lengths of PR intervals (Figure 4, horizontal arrow). These observed features suggest that the most likely diagnosis is a triple ventricular response1 or triple fire attributable to triple atrioventricular nodal pathway conduction. It is a nonreentrant atrioventricular nodal tachycardia, as is dual atrioventricular nodal nonreentrant tachycardia2; that is, each sinus beat is simultaneously conducted through the anterograde fast, intermediate, and slow atrioventricular nodal pathways and creates triple QRS waves for each P wave.Download figureDownload PowerPointFigure 4. Annotated Holter monitor recording. Stars indicate the P waves (Note that the P waves are hidden in the QRS wave, ST segment, or T wave). The short, medium, and long horizontal arrows indicate short, medium, and long PR intervals, respectively. The 3 different PR intervals were the clue that suggested triple fire because they showed 3 different pathway connections.Sustained triple ventricular response leads to extremely rapid repetitive activation of the ventricle, which may lead to intermittent functional bundle-branch block. This explains why the second and third QRS waves in each group show different degrees of aberration (Figure 3). It is noteworthy that the triple ventricular response does not always occur continuously. When the intermediate or slow pathways are in a refractory period, the atrial impulse is conducted only via the other 2 pathways, resulting in a dual ventricular response in different combinations (Figure 3, red stars).3The patient underwent an electrophysiology study, which confirmed the presence of triple atrioventricular nodal physiology and 1:3 atrioventricular conduction during sinus rhythm. The intracardiac electrogram (Figure 5) showed that the first and third sinus beats were followed by 3 sequential atrial His (AH) intervals (AH1, AH2, and AH3), suggesting simultaneous conduction over the fast, intermediate, and slow AV nodal pathways. There was no retrograde conduction over the atrioventricular node, and no atrioventricular nodal reentrant tachycardia could be induced.Download figureDownload PowerPointFigure 5. Intracardiac electrogram. The intracardiac recording shows 3 His signals (H1, H2, and H3) and 3 ventricular electrograms (V1, V2, and V3) for the first and third atrial signal electrograms (A). These findings confirm that atrial impulse is simultaneously conducted through the anterograde fast and intermediate pathways, which confirmed the presence of triple ventricular response. FP indicates fast pathway; MP, intermediate pathway; and SP, slow pathway.Successful ablation of 2 slow pathways terminated the arrhythmia and restored 1:1 atrioventricular conduction. At the 3- and 8-month follow-up visits, the patient reported no recurrence of symptoms.To the best of our knowledge, this is the first report of an ECG that shows triple ventricular response. Dual ventricular response has been reported in numerous reports. We are aware of just 1 other article by Arias et al,1 but only intracardiac recordings were presented, not a surface 12-lead ECG. The irregularity of dual and triple ventricular response may lead to an incorrect diagnosis such as atrial fibrillation, premature atrial contractions, or ventricular tachycardia.Disclosures None.Footnoteshttps://www.ahajournals.org/journal/circDing Peng, MD, Department of Cardiology, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People’s Hospital, B24 Yinquan South Rd, Qingyuan 511518, Guang Dong Province, People’s Republic of China. Email [email protected]comReferences1. Arias MA, Puchol A, Castellanos E, Rodríguez-Padial L. Triple atrioventricular nodal response to an atrial impulse.Heart Rhythm. 2010; 7:716–717. doi: 10.1016/j.hrthm.2009.07.039CrossrefMedlineGoogle Scholar2. Peiker C, Pott C, Eckardt L, Kelm M, Shin DI, Willems S, Meyer C. Dual atrioventricular nodal non-re-entrant tachycardia.Europace. 2016; 18:332–339. doi: 10.1093/europace/euv056CrossrefMedlineGoogle Scholar3. Pott C, Wegner FK, Bögeholz N, Frommeyer G, Dechering DG, Zellerhoff S, Kochhäuser S, Milberg P, Köbe J, Wasmer K, et al.. A patient series of dual atrioventricular nodal nonreentrant tachycardia (DAVNNT): an often overlooked diagnosis?Int J Cardiol. 2014; 172:e9–e11. doi: 10.1016/j.ijcard.2013.12.109CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Raphael C and Pavri B (2022) An unusual case of non‐reentrant atrioventricular nodal tachycardia, Journal of Cardiovascular Electrophysiology, 10.1111/jce.15426, 33:5, (1062-1066), Online publication date: 1-May-2022. March 16, 2021Vol 143, Issue 11 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.052913PMID: 33720769 Originally publishedMarch 15, 2021 PDF download Advertisement SubjectsArrhythmiasElectrophysiology