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Automated external defibrillator documented degeneration of pre-excited atrial fibrillation into ventricular fibrillation
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ScienceDirect Journal of Electrocardiology 46 (2013) 663 – 665 www.jecgonline.com
Automated external defibrillator documented degeneration of pre-excited atrial fibrillation into ventricular fibrillation Kazuhiro Takahashi, MD, PhD,⁎ Yoshimitsu Ohtsuka, MD, Atsuya Shimabukuro, MD, Akira Miyake, MD, Taisuke Nabeshima, MD, Mami Nakayashiro, MD Department of Pediatric Cardiology, Okinawa Children's Medical Center, Okinawa, Japan Received 8 November 2012
Abstract
Wolff–Parkinson–White (WPW) syndrome can be the cause of syncope or sudden cardiac death, which results from ventricular fibrillation (VF) degenerated from rapid anterograde conduction of atrial fibrillation (AF) to the ventricles through the accessory pathway. We present a case of WPW syndrome in which recording the actual moment of onset of the degeneration of pre-excited AF into VF. This was fortuitous and also lucky for this patient. © 2013 Elsevier Inc. All rights reserved.
Keywords:
Sudden cardiac death; WPW syndrome; Automated external defibrillator
Introduction Wolff–Parkinson–White (WPW) syndrome can be the cause of syncope or sudden cardiac death (SCD), resulting from rapid anterograde conduction of atrial fibrillation (AF) to the ventricles through the accessory pathway. Recording the actual moment of onset of cardiac arrest in patients with WPW syndrome is rare.
Case report The patient was an otherwise healthy 14-year-old girl diagnosed with WPW syndrome and supraventricular tachycardia during the neonatal period. Her 12-lead electrocardiogram (ECG) in sinus rhythm confirmed pre-excitation with a short PR interval and a delta wave consistent with a left accessory pathway. Her family history was unremarkable and echocardiography was normal. She became asymptomatic later and dropped out of follow-up. For the past few years, she has felt occasional palpitations, and has terminated the tachycardia each time by the Valsalva maneuver. She has not received any medication. One day she experienced persistent palpitations while walking outside. The palpitations lasted N 2 h despite multiple Valsalva maneuver to terminate the tachycardia. Thereafter, she had an intermittent loss of ⁎ Corresponding author. Department of Pediatric Cardiology, Okinawa Children's Medical Center, 118–1 Arakawa, Haebaru-cho, Okinawa 901– 1193, Japan. E-mail address: [email protected] 0022-0736/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jelectrocard.2013.01.007
consciousness and had seizures. Therefore, her mother called an ambulance. An automated external defibrillator (AED) was placed on her as a monitor. The initial rhythm recorded was a broad, complex irregular tachycardia with the shortest pre-excited R–R interval of b 200 ms and intermittent irregular narrow QRS tachycardia. No discernible P waves were seen (Fig. 1A). The terminal portion of the rhythm strip showed degeneration of the pre-excited AF into ventricular fibrillation (VF) or polymorphic ventricular tachycardia, and, therefore, records the exact moment and cause of cardiac arrest (Fig. 1B). These events occurred twice during transport, and shock administration was advised. But defibrillation was withheld at the paramedic's judgment because chest compressions by the paramedics converted VF to AF, and she had regained consciousness immediately. The third VF event occurred when the patient was transferred to our emergency department. At that time, VF and AF were defibrillated to sinus rhythm on the spot. This patient developed VF that was documented by an AED monitor. Thereafter, she underwent coronary angiography and an electrophysiological study (EPS). Her coronary angiogram was normal, and AF was easily and reproducibly induced by programmed electrical stimulation during EPS. Her surface ECG during atrial pacing revealed manifest delta wave (Fig. 2, left panel). The QRS morphology on the lead II was similar to that on the AED. Her anterograde accessory pathway ERP was 260 ms. The shortest pre-excited RR interval was 250 ms without isoproterenol infusion. Radiofrequency (RF) energy application for the left posterolateral accessory pathway eliminated the conduction through the
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K. Takahashi et al. / Journal of Electrocardiology 46 (2013) 663–665
Fig. 1. An automated external defibrillator (AED) strip. A, The initial rhythm recorded was a broad, complex irregular tachycardia with a minimal pre-excited R–R interval b 200 ms, and an intermittent irregular narrow QRS tachycardia. No discernible P-waves were seen. B, The terminal portion of the rhythm strip shows degeneration of this pre-excited atrial fibrillation into ventricular fibrillation, and, therefore, records the exact moment and cause of cardiac arrest.
accessory pathway (Fig. 2, right panel). AF was never induced after the successful RF catheter ablation. Neither delta wave nor AF has occurred on 12-lead ECG for 6 months of the follow-up. She has never experienced any symptoms such as palpitation.
Discussion Although the majority of initially symptomatic patients with WPW remain asymptomatic after the first episode of supraventricular tachycardia or may experience a benign recurrence over the follow-up period, 1 some patients can experience catastrophic arrhythmic events, including syncope and/or cardiac arrest. 2–4 We could not predict the risk of sudden cardiac death from any of the EPS parameters in the present patient because her shortest pre-excited RR interval on AED was quite shorter than that at EPS. The risk of sudden cardiac death is always present with WPW syndrome, and it motivates us to evaluate and treat the syndrome. 5
Recording the actual moment of onset of degeneration of the pre-excited AF into VF in a patient with WPW syndrome is quite rare because VF is a life-threatening arrhythmia that requires immediate cardioversion and rarely self-terminating. The precise mechanism of self-termination of VF is unknown in the present case. Self-terminating polymorphic VT has been previously described in patients with coronary artery disease and a normal QT interval or otherwise healthy patients with recurrent syncope. 6 Although it is difficult to rule out artifacts recording with the AED, more organized polymorphic VT might have been repeated before the last VF episode in the present case. This was fortuitous and this young girl was lucky. References 1. Cohen MI, Triedman JK, et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a WolffParkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society
K. Takahashi et al. / Journal of Electrocardiology 46 (2013) 663–665
665
Fig. 2. Surface 12-lead electrocardiograms with atrial pacing during EPS, showing a maximal pre-excitation at baseline (left panel), no delta-wave after the ablation (right panel).
(HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association mmj(AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm 2012;9:1006. 2. Klein GJ, Bashore TM, et al. Ventricular fibrillation in the WolffParkinson-White syndrome. N Engl J Med 1979;301:1080. 3. Theunissen L, Rodriguez LM, Timmermans C. A suddenly lethal accessory pathway. J Electrocardiol 2012;45:176.
4. Obeyesekere M, Gula LJ, et al. Risk of sudden death in Wolff-ParkinsonWhite syndrome: how high is the risk? Circulation 2012;125:659–60. 5. Pappone C, Vicedomini G, et al. Risk of malignant arrhythmias in initially symptomatic patients with Wolff-Parkinson-White syndrome: results of a prospective long-term electrophysiological follow-up study. Circulation 2012;125:661. 6. Konstantino Y, Morello A, Zimetbaum PJ, Josephson ME. Selfterminated ventricular fibrillation and recurrent syncope. Am J Cardiol 2011;107:638.
ScienceDirect Journal of Electrocardiology 46 (2013) 663 – 665 www.jecgonline.com
Automated external defibrillator documented degeneration of pre-excited atrial fibrillation into ventricular fibrillation Kazuhiro Takahashi, MD, PhD,⁎ Yoshimitsu Ohtsuka, MD, Atsuya Shimabukuro, MD, Akira Miyake, MD, Taisuke Nabeshima, MD, Mami Nakayashiro, MD Department of Pediatric Cardiology, Okinawa Children's Medical Center, Okinawa, Japan Received 8 November 2012
Abstract
Wolff–Parkinson–White (WPW) syndrome can be the cause of syncope or sudden cardiac death, which results from ventricular fibrillation (VF) degenerated from rapid anterograde conduction of atrial fibrillation (AF) to the ventricles through the accessory pathway. We present a case of WPW syndrome in which recording the actual moment of onset of the degeneration of pre-excited AF into VF. This was fortuitous and also lucky for this patient. © 2013 Elsevier Inc. All rights reserved.
Keywords:
Sudden cardiac death; WPW syndrome; Automated external defibrillator
Introduction Wolff–Parkinson–White (WPW) syndrome can be the cause of syncope or sudden cardiac death (SCD), resulting from rapid anterograde conduction of atrial fibrillation (AF) to the ventricles through the accessory pathway. Recording the actual moment of onset of cardiac arrest in patients with WPW syndrome is rare.
Case report The patient was an otherwise healthy 14-year-old girl diagnosed with WPW syndrome and supraventricular tachycardia during the neonatal period. Her 12-lead electrocardiogram (ECG) in sinus rhythm confirmed pre-excitation with a short PR interval and a delta wave consistent with a left accessory pathway. Her family history was unremarkable and echocardiography was normal. She became asymptomatic later and dropped out of follow-up. For the past few years, she has felt occasional palpitations, and has terminated the tachycardia each time by the Valsalva maneuver. She has not received any medication. One day she experienced persistent palpitations while walking outside. The palpitations lasted N 2 h despite multiple Valsalva maneuver to terminate the tachycardia. Thereafter, she had an intermittent loss of ⁎ Corresponding author. Department of Pediatric Cardiology, Okinawa Children's Medical Center, 118–1 Arakawa, Haebaru-cho, Okinawa 901– 1193, Japan. E-mail address: [email protected] 0022-0736/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jelectrocard.2013.01.007
consciousness and had seizures. Therefore, her mother called an ambulance. An automated external defibrillator (AED) was placed on her as a monitor. The initial rhythm recorded was a broad, complex irregular tachycardia with the shortest pre-excited R–R interval of b 200 ms and intermittent irregular narrow QRS tachycardia. No discernible P waves were seen (Fig. 1A). The terminal portion of the rhythm strip showed degeneration of the pre-excited AF into ventricular fibrillation (VF) or polymorphic ventricular tachycardia, and, therefore, records the exact moment and cause of cardiac arrest (Fig. 1B). These events occurred twice during transport, and shock administration was advised. But defibrillation was withheld at the paramedic's judgment because chest compressions by the paramedics converted VF to AF, and she had regained consciousness immediately. The third VF event occurred when the patient was transferred to our emergency department. At that time, VF and AF were defibrillated to sinus rhythm on the spot. This patient developed VF that was documented by an AED monitor. Thereafter, she underwent coronary angiography and an electrophysiological study (EPS). Her coronary angiogram was normal, and AF was easily and reproducibly induced by programmed electrical stimulation during EPS. Her surface ECG during atrial pacing revealed manifest delta wave (Fig. 2, left panel). The QRS morphology on the lead II was similar to that on the AED. Her anterograde accessory pathway ERP was 260 ms. The shortest pre-excited RR interval was 250 ms without isoproterenol infusion. Radiofrequency (RF) energy application for the left posterolateral accessory pathway eliminated the conduction through the
664
K. Takahashi et al. / Journal of Electrocardiology 46 (2013) 663–665
Fig. 1. An automated external defibrillator (AED) strip. A, The initial rhythm recorded was a broad, complex irregular tachycardia with a minimal pre-excited R–R interval b 200 ms, and an intermittent irregular narrow QRS tachycardia. No discernible P-waves were seen. B, The terminal portion of the rhythm strip shows degeneration of this pre-excited atrial fibrillation into ventricular fibrillation, and, therefore, records the exact moment and cause of cardiac arrest.
accessory pathway (Fig. 2, right panel). AF was never induced after the successful RF catheter ablation. Neither delta wave nor AF has occurred on 12-lead ECG for 6 months of the follow-up. She has never experienced any symptoms such as palpitation.
Discussion Although the majority of initially symptomatic patients with WPW remain asymptomatic after the first episode of supraventricular tachycardia or may experience a benign recurrence over the follow-up period, 1 some patients can experience catastrophic arrhythmic events, including syncope and/or cardiac arrest. 2–4 We could not predict the risk of sudden cardiac death from any of the EPS parameters in the present patient because her shortest pre-excited RR interval on AED was quite shorter than that at EPS. The risk of sudden cardiac death is always present with WPW syndrome, and it motivates us to evaluate and treat the syndrome. 5
Recording the actual moment of onset of degeneration of the pre-excited AF into VF in a patient with WPW syndrome is quite rare because VF is a life-threatening arrhythmia that requires immediate cardioversion and rarely self-terminating. The precise mechanism of self-termination of VF is unknown in the present case. Self-terminating polymorphic VT has been previously described in patients with coronary artery disease and a normal QT interval or otherwise healthy patients with recurrent syncope. 6 Although it is difficult to rule out artifacts recording with the AED, more organized polymorphic VT might have been repeated before the last VF episode in the present case. This was fortuitous and this young girl was lucky. References 1. Cohen MI, Triedman JK, et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a WolffParkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society
K. Takahashi et al. / Journal of Electrocardiology 46 (2013) 663–665
665
Fig. 2. Surface 12-lead electrocardiograms with atrial pacing during EPS, showing a maximal pre-excitation at baseline (left panel), no delta-wave after the ablation (right panel).
(HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association mmj(AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm 2012;9:1006. 2. Klein GJ, Bashore TM, et al. Ventricular fibrillation in the WolffParkinson-White syndrome. N Engl J Med 1979;301:1080. 3. Theunissen L, Rodriguez LM, Timmermans C. A suddenly lethal accessory pathway. J Electrocardiol 2012;45:176.
4. Obeyesekere M, Gula LJ, et al. Risk of sudden death in Wolff-ParkinsonWhite syndrome: how high is the risk? Circulation 2012;125:659–60. 5. Pappone C, Vicedomini G, et al. Risk of malignant arrhythmias in initially symptomatic patients with Wolff-Parkinson-White syndrome: results of a prospective long-term electrophysiological follow-up study. Circulation 2012;125:661. 6. Konstantino Y, Morello A, Zimetbaum PJ, Josephson ME. Selfterminated ventricular fibrillation and recurrent syncope. Am J Cardiol 2011;107:638.