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Challenges in Clinical Electrocardiography |

A Case of Ventricular Arrhythmia When the Right Isn’t Right

Shing Ching, MBBS1; Chiu Sun Yue, MBBS, MRCP1
[+] Author Affiliations
1Division of Cardiology, Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong, China
JAMA Intern Med. 2016;176(7):1013-1015. doi:10.1001/jamainternmed.2016.1982.
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A woman in her 60s presented to the emergency department with palpitation and dyspnea. Her blood pressure was 154/78 mm Hg, her pulse was 184 beats per minute, and the arrhythmia did not respond to adenosine. What is your diagnosis?

A woman in her 60s presented to the emergency department with palpitation and dyspnea. She had multiple syncopal episodes months prior. Her blood pressure was 154/78 mm Hg, her pulse was 184 beats per minute, and her arterial oxygen saturation was 98% breathing ambient air. Her electrocardiogram (ECG) is shown (Figure 1A). The arrhythmia did not respond to adenosine. Following amiodarone infusion, a second ECG test was performed (Figure 1B).

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Figure 1.
Patient Electrocardiograms

A, Initial electrocardiogram showing regular wide-complex tachycardia with left bundle-branch block morphology and inferior axis. P-waves march through the QRS indicative of atrioventricular dissociation (red arrowhead). A fusion beat (star) is noted at the right side of the strip preceded by a P-wave (black arrowhead); B, Electrocardiogram following pharmacologic cardioversion. QRS in V1 appears fragmented. Note T wave inversion in leads V1 to V5.

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Figure 2.
Enlarged View of Lead V1

Enlarged view of lead V1. Note that this is not right bundle-branch block. Black arrowhead points to the epsilon wave. Terminal activation delay (TAD), taken from nadir of the S wave to the end of all depolarization before the T wave, is prolonged at 90 milliseconds (normal being < 55 milliseconds).

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Figure 3.
Transthoracic Echocardiogram

A, Parasternal short axis view at the aortic valve level showing a dilated RV outflow tract; B, dilated proximal RV outflow tract shown in parasternal long axis view; C, subcostal four-chamber view demonstrating RV free wall akinesia and thinning (white arrowhead); D, normal peak tricuspid regurgitation velocity indicating absence of significant pulmonary hypertension.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Parasternal Long Axis

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Parasternal Short Axis

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Subcostal Four-Chamber View

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