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Reversible tachycardia mediated cardiomyopathy after radiofrequency ablation of idiopathic left ventricular tachycardia
International Journal of Cardiology 176 (2014) e5–e8
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Reversible tachycardia mediated cardiomyopathy after radiofrequency ablation of idiopathic left ventricular tachycardia Jia He, Pi-Hua Fang ⁎, Zheng Liu, Xiong-Biao Chen, Jun Liu, Min Tang, Yu-He Jia, Shu Zhang Center for Arrhythmia Diagnosis and Treatment, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
a r t i c l e
i n f o
Article history: Received 26 April 2014 Accepted 28 June 2014 Available online 6 July 2014 Keywords: Idiopathic left ventricular tachycardia Tachycardia mediated cardiomyopathy Radiofrequency ablation
A 20-year-old girl was admitted to our hospital with a chief complain of 12-days of palpitation and progressive shortness of breath. The symptoms of heart failure were consistent with New York Heart Association (NYHA) grade III. She had fever and cold symptoms 2-days before the onset of palpitation and heart failure symptoms but recovered soon, without other significant medical history. Physical examination demonstrates a heart rate of 170 beats per minute (bpm), a blood pressure of 70/40 mm Hg and bibasilar rales. ECG revealed a relatively narrow QRS tachycardia of 170 bpm with right bundle branch block (RBBB) morphology and a superior left axis configuration (Fig. 1a). At the emergency department, empirical administration of intravenous verapamil was implemented and sinus rhythm was restored within 3 min with inverted T wave in leads II, III, aVF and V3–6 (Fig. 1b). A chest X-ray revealed bilateral plural effusion and increased cardiothoracic ratio (Fig. 2a). Transthoracic echocardiography performed demonstrated marginal left ventricular dysfunction (left ventricular ejection fraction [LVEF] of 50%), with a normal LV end-diastolic diameter (LVEDD) of 38 mm and cardiac effusion with a fluid sonolucent area of 6 mm. Electrophysiological study performed in the following day after administration induced narrow QRS tachycardia which did not replicate the clinical morphology and indicated atrio-ventricular tachycardia via left atrio-ventricular bypass (Fig. 3a), while the tachycardia of clinical morphology was not induced. The atrio-ventricular bypass was successfully ablated and the pre-systolic Purkinje potentials (Fig. 3b) were targeted,
⁎ Corresponding author at: Center for Arrhythmias Diagnosis and Treatment, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, BeiLiShi Road 167#, 100037 Beijing, China. Fax: +86 10 88298867. E-mail address: [email protected] (P.-H. Fang).
http://dx.doi.org/10.1016/j.ijcard.2014.06.060 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
resulting in a new Q wave in inferior leads of ECG which mimics left posterior fascicular block after ablation (Fig. 1c). Chest X-ray performed in the 2nd day (Fig. 2b), the 3rd day (Fig. 2c) and the 40th day (Fig. 2d) revealed decreased and demission of plural effusion and decrease cardiothoracic ratio. Transthoracic echocardiography performed in the 3rd day demonstrated normalization of left ventricular dysfunction (LVEF of 76.6%) and cardiac effusion with a fluid sonolucent area of 6 mm, while in the 40th day the cardiac effusion was diminished. ECG in the 40th day revealed T wave restored upright (Fig. 1d). The patient remained free from arrhythmia for 2 months, without anti-arrhythmic medication. Tachycardia mediated cardiomyopathy (TMC) is a reversible form of dilated cardiomyopathy characterized by new onset ventricular systolic and diastolic dysfunction simultaneous with prolonged tachycardia, and the diagnosis should preclude other causes of ischemic or non-ischemic cardiomyopathy. Although it is somewhat a form of dilated cardiomyopathy, LV dimensions are relatively normal. One of the critical characteristics is the recovery of LV function after control of tachycardia within one to six months [1]. TMC occurs with most supraventricular and ventricular arrhythmias while more commonly associated with supraventricular tachycardia, particularly atrial fibrillation with rapid ventricular rate [2]. Ventricular arrhythmias including idiopathic left ventricular tachycardia (ILVT) are less common reasons of TMC mostly because they usually cause hemodynamic instability which require emergency cardioversion before it causes TMC. The case we report is with relatively narrow QRS tachycardia having minor adverse effect on hemodynamic stability, which is consistent with the two cases reported earlier [3]. Actually the patient was transfer from another hospital. Because ILVT induced TMC is uncommon; and the most prominent characteristics of the patient are severe heart failure, plural effusion and cardiac effusion with pre-symptoms of fever and cold, careful diagnosis of ECG was ignored, the tachycardia was then considered to be the result of some structural heart diseases or systemic diseases other than the cause of these symptoms. Idiopathic left ventricular tachycardia (ILVT) is typically characterized by sensitivity to verapamil, and RBBB morphology with a left axis configuration on the electrocardiogram. It has been demonstrated that ILVT originates from the Purkinje network of the left posterior fascicle, and Purkinje potentials indicate successful ablation target site [4]. So if tachycardia cannot be induced, successful ablation can be achieved by Purkinje potential guiding and new or deepening Q wave in inferior leads is considered as an effective endpoint in ablation [5]. It is reported
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J. He et al. / International Journal of Cardiology 176 (2014) e5–e8
that among patients with IVLT, 5% had a concomitant left accessory pathway (AP), and idiopathic left ventricular tachycardia and AP should be ablated simultaneously [6]. In conclusion, we learn from this case that IVLT induced TMC is completely reversible as demonstrated by recovery of clinical symptoms, ECG, chest X-ray and transthoracic echocardiography. Radiofrequency ablation is an effect approach for IVLT induced TMC. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] Gupta S, Figueredo VM. Tachycardia mediated cardiomyopathy: Pathophysiology, mechanisms, clinical features and management. International journal of cardiology 2014;172:40–6. [2] Nakatani BT, et al. Tachycardia-induced cardiomyopathy. BMJ Case Rep 2012. http:// dx.doi.org/10.1136/bcr-2012-006587. [3] Castro-Rodriguez J, Verbeet T, Morissens M, et al. Complicated formsof tachycardiamediated cardiomyopathy associated with idiopathic left ventricular tachycardia. Pacing and clinical electrophysiology: PACE 2011;34:e52–5. [4] Nakagawa H, Beckman KJ, McClelland JH, et al. Radiofrequency catheter ablation of idiopathic left ventricular tachycardia guided by a Purkinje potential. Circulation 1993;88(6):2607–17. [5] Yao SY, Chu JM, Fang PH, et al. The morphology changes in limb leads after ablation of verapamil-sensitive idiopathic left ventricular tachycardia and their correlation with recurrence. J Cardiovasc Electrophysiol 2008;19(3):238–41. [6] Hu JQ, Ma J, Yang Q, et al. The characteristics of verapamil-sensitive idiopathic left ventricular tachycardia combined with a left accessory pathway and the effect of radiofrequency catheter ablation. Europace 2012;14(5):703–8.
Fig. 1. ECG of idiopathic left ventricular tachycardia (a), restored sinus rhythm after administration of verapamil (b), after ablation (c) and follow up in the 40th day (d).
J. He et al. / International Journal of Cardiology 176 (2014) e5–e8
Fig. 2. Chest x ray at administration (a), the 2nd day (b), the 3rd day (c) and the 40th day (d).
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J. He et al. / International Journal of Cardiology 176 (2014) e5–e8
Fig. 3. Intracardiac electrogram of tachycardia via left atrio-ventricular bypass (a) and Purkinje potentials (arrows) (b).
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Reversible tachycardia mediated cardiomyopathy after radiofrequency ablation of idiopathic left ventricular tachycardia Jia He, Pi-Hua Fang ⁎, Zheng Liu, Xiong-Biao Chen, Jun Liu, Min Tang, Yu-He Jia, Shu Zhang Center for Arrhythmia Diagnosis and Treatment, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
a r t i c l e
i n f o
Article history: Received 26 April 2014 Accepted 28 June 2014 Available online 6 July 2014 Keywords: Idiopathic left ventricular tachycardia Tachycardia mediated cardiomyopathy Radiofrequency ablation
A 20-year-old girl was admitted to our hospital with a chief complain of 12-days of palpitation and progressive shortness of breath. The symptoms of heart failure were consistent with New York Heart Association (NYHA) grade III. She had fever and cold symptoms 2-days before the onset of palpitation and heart failure symptoms but recovered soon, without other significant medical history. Physical examination demonstrates a heart rate of 170 beats per minute (bpm), a blood pressure of 70/40 mm Hg and bibasilar rales. ECG revealed a relatively narrow QRS tachycardia of 170 bpm with right bundle branch block (RBBB) morphology and a superior left axis configuration (Fig. 1a). At the emergency department, empirical administration of intravenous verapamil was implemented and sinus rhythm was restored within 3 min with inverted T wave in leads II, III, aVF and V3–6 (Fig. 1b). A chest X-ray revealed bilateral plural effusion and increased cardiothoracic ratio (Fig. 2a). Transthoracic echocardiography performed demonstrated marginal left ventricular dysfunction (left ventricular ejection fraction [LVEF] of 50%), with a normal LV end-diastolic diameter (LVEDD) of 38 mm and cardiac effusion with a fluid sonolucent area of 6 mm. Electrophysiological study performed in the following day after administration induced narrow QRS tachycardia which did not replicate the clinical morphology and indicated atrio-ventricular tachycardia via left atrio-ventricular bypass (Fig. 3a), while the tachycardia of clinical morphology was not induced. The atrio-ventricular bypass was successfully ablated and the pre-systolic Purkinje potentials (Fig. 3b) were targeted,
⁎ Corresponding author at: Center for Arrhythmias Diagnosis and Treatment, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, BeiLiShi Road 167#, 100037 Beijing, China. Fax: +86 10 88298867. E-mail address: [email protected] (P.-H. Fang).
http://dx.doi.org/10.1016/j.ijcard.2014.06.060 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
resulting in a new Q wave in inferior leads of ECG which mimics left posterior fascicular block after ablation (Fig. 1c). Chest X-ray performed in the 2nd day (Fig. 2b), the 3rd day (Fig. 2c) and the 40th day (Fig. 2d) revealed decreased and demission of plural effusion and decrease cardiothoracic ratio. Transthoracic echocardiography performed in the 3rd day demonstrated normalization of left ventricular dysfunction (LVEF of 76.6%) and cardiac effusion with a fluid sonolucent area of 6 mm, while in the 40th day the cardiac effusion was diminished. ECG in the 40th day revealed T wave restored upright (Fig. 1d). The patient remained free from arrhythmia for 2 months, without anti-arrhythmic medication. Tachycardia mediated cardiomyopathy (TMC) is a reversible form of dilated cardiomyopathy characterized by new onset ventricular systolic and diastolic dysfunction simultaneous with prolonged tachycardia, and the diagnosis should preclude other causes of ischemic or non-ischemic cardiomyopathy. Although it is somewhat a form of dilated cardiomyopathy, LV dimensions are relatively normal. One of the critical characteristics is the recovery of LV function after control of tachycardia within one to six months [1]. TMC occurs with most supraventricular and ventricular arrhythmias while more commonly associated with supraventricular tachycardia, particularly atrial fibrillation with rapid ventricular rate [2]. Ventricular arrhythmias including idiopathic left ventricular tachycardia (ILVT) are less common reasons of TMC mostly because they usually cause hemodynamic instability which require emergency cardioversion before it causes TMC. The case we report is with relatively narrow QRS tachycardia having minor adverse effect on hemodynamic stability, which is consistent with the two cases reported earlier [3]. Actually the patient was transfer from another hospital. Because ILVT induced TMC is uncommon; and the most prominent characteristics of the patient are severe heart failure, plural effusion and cardiac effusion with pre-symptoms of fever and cold, careful diagnosis of ECG was ignored, the tachycardia was then considered to be the result of some structural heart diseases or systemic diseases other than the cause of these symptoms. Idiopathic left ventricular tachycardia (ILVT) is typically characterized by sensitivity to verapamil, and RBBB morphology with a left axis configuration on the electrocardiogram. It has been demonstrated that ILVT originates from the Purkinje network of the left posterior fascicle, and Purkinje potentials indicate successful ablation target site [4]. So if tachycardia cannot be induced, successful ablation can be achieved by Purkinje potential guiding and new or deepening Q wave in inferior leads is considered as an effective endpoint in ablation [5]. It is reported
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J. He et al. / International Journal of Cardiology 176 (2014) e5–e8
that among patients with IVLT, 5% had a concomitant left accessory pathway (AP), and idiopathic left ventricular tachycardia and AP should be ablated simultaneously [6]. In conclusion, we learn from this case that IVLT induced TMC is completely reversible as demonstrated by recovery of clinical symptoms, ECG, chest X-ray and transthoracic echocardiography. Radiofrequency ablation is an effect approach for IVLT induced TMC. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] Gupta S, Figueredo VM. Tachycardia mediated cardiomyopathy: Pathophysiology, mechanisms, clinical features and management. International journal of cardiology 2014;172:40–6. [2] Nakatani BT, et al. Tachycardia-induced cardiomyopathy. BMJ Case Rep 2012. http:// dx.doi.org/10.1136/bcr-2012-006587. [3] Castro-Rodriguez J, Verbeet T, Morissens M, et al. Complicated formsof tachycardiamediated cardiomyopathy associated with idiopathic left ventricular tachycardia. Pacing and clinical electrophysiology: PACE 2011;34:e52–5. [4] Nakagawa H, Beckman KJ, McClelland JH, et al. Radiofrequency catheter ablation of idiopathic left ventricular tachycardia guided by a Purkinje potential. Circulation 1993;88(6):2607–17. [5] Yao SY, Chu JM, Fang PH, et al. The morphology changes in limb leads after ablation of verapamil-sensitive idiopathic left ventricular tachycardia and their correlation with recurrence. J Cardiovasc Electrophysiol 2008;19(3):238–41. [6] Hu JQ, Ma J, Yang Q, et al. The characteristics of verapamil-sensitive idiopathic left ventricular tachycardia combined with a left accessory pathway and the effect of radiofrequency catheter ablation. Europace 2012;14(5):703–8.
Fig. 1. ECG of idiopathic left ventricular tachycardia (a), restored sinus rhythm after administration of verapamil (b), after ablation (c) and follow up in the 40th day (d).
J. He et al. / International Journal of Cardiology 176 (2014) e5–e8
Fig. 2. Chest x ray at administration (a), the 2nd day (b), the 3rd day (c) and the 40th day (d).
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Fig. 3. Intracardiac electrogram of tachycardia via left atrio-ventricular bypass (a) and Purkinje potentials (arrows) (b).