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A Complex Rhythm Treated Simply: Fascicular Ventricular Tachycardia

Published:December 06, 2013DOI:https://doi.org/10.1016/j.amjmed.2013.11.009
      A patient with no known history of ischemic or structural heart disease developed a ventricular tachyarrhythmia from a somewhat uncommon cause. The 57-year-old man presented to the emergency department with an initial complaint of several days of abdominal pain. During examination, he was found to have an irregular rapid heart rate. A 12-lead electrocardiogram (ECG) revealed a wide-complex tachycardia at a rate of 186 beats per minute (Figure 1A) with 2:1 ventriculoatrial conduction (Figure 2). The patient denied any active or prior chest pain, palpitations, presyncope, or syncope.
      Figure thumbnail gr1
      Figure 1(A) A 12-lead electrocardiogram (ECG) was obtained upon the patient's admission. It showed a regular wide complex tachycardia at 186 beats per minute and a QRS interval of 138 msec. The rhythm had typical right bundle branch block (RBBB) and left anterior fascicular block (LAFB) morphology (as seen with left-axis deviation). The conduction vector demonstrated a bifascicular block, suggesting that the origin of the wide complex tachycardia was the left posterior fascicular focus. In addition, 2:1 ventriculoatrial conduction was seen, showing intermittent retrograde conduction from the ventricle to the atrium (arrows). (B) The 12-lead ECG ordered after cardioversion showed a sinus rhythm of 56 beats per minute, LAFB, deep T-wave inversions in the inferior leads, and ST-T segment abnormalities in the lateral leads.
      Figure thumbnail gr2
      Figure 2This magnified section of concentrates on leads II, III, and V1 and demonstrates 2:1 ventriculoatrial conduction. An orange line is used to simultaneously align the retrograde p waves in the leads displayed. A QRS complex and a p wave are superimposed (in blue) on a QRS complex without retrograde atrial conduction to show the negative vector of the p wave (arrow) in lead II that is embedded within the up-sloping portion of the ST segment.
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