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Ecg of the month

Wide complex tachycardiaVT vs SVT Presented by Dr Neeraj Nirala

GUIDEDr Neera SamarUNIT HEADDr R.L. MeenaCASE 150 yr old male, labourer, smoker with H/O OF MI 5yr back admitted in ICCU with c/o of palpitation, feeling of uneasiness for duration of 4-6 hrs. no h/o chest pain, dyspnoea, syncope o/e- conscious,oriented no pallor, cyanosis, clubbing, edema JVP raised. BP- 80/60 mm hg Ecg at time of admission (before dc)

Ecg at time of admission

Ecg -after dc cardioversion (200j)

Differential diagnosisVentricular tachycardia

Supra ventricular tachycardia with abberant conduction due to right or left BBBDiscussion wide complex tachycardiasDefinitionEcg featuresDiagnostic criteria - Brugada criteria - Lead aVR algorithm - Ultrasimple Brugada criterion: RW to peak Time (RWPT)

Definition

Wide QRS complex tachycardia is a rhythm with a rate of more than 100 b/m and QRS duration of more than 120 ms

VT (80%)SVT (20%)VT- Non-sustained VT: three or more ventricular beats with a maximal duration of 30 seconds.Sustained VT: a VT of more than 30 seconds duration (or less if treated by electrocardioversion within 30 seconds).Monomorphic VT: all ventricular beats have the same configuration.Polymorphic VT: the ventricular beats have a changing configuration. The RR interval is 180-600 ms Biphasic VT: a ventricular tachycardia with a QRS complex that alternates from beat to beat.

SVT- a tachycardia dependent on participation of structure at or above bundle of HisLBBB morphology- QRS > 12 msec. with prominent negative deflection in V1

RBBB morphology- QRS > 12 msec. with prominent positive deflection in V1.Physical examinationSigns of AV dissociation favours VT - cannon waves - varying intensity of S1 - variation of systolic BP - hypotension

Termination of WCT with maneuvers ~ carotid,vasalva,adenosine favours SVTBrugada criteria

Step 1- rs complex in precordial leads

Step 2- r to nadir of s (brugada sign)

step 3- a-v dissociation

Step.4- qrs morphology

Other ecg findings favour vtNorth - west QRS axis deviation i.e superior and rightward minus 90 degree to 180 degreeNegative or positive concordance of QRS complex in all precordial leads AV dissociaton : Fusion beats, capture beatsIn LBBB, QRS duration >160 msIn RBBB,QRS duration > 140 msPrevious ECG show MI

Rabbit ear IN rbbb PATTERN

Concordance & north west axis

Positive concordance

Fusion & capture beats

A fusion beat is descriptive term for the merging of an ectopic beat and a capture beat. When an ectopic rhythm is present, as in ventricular tachycardia, the ectopic foci may conduct in a retrograde direction. If the ventricles are not refractory, this leads to a conducted P wave that causes a normal QRS to follow. This is a capture beat. However, when the ectopic focus fires at the same time that the P wave reaches the ventricles, the QRS is a "combination" of the capture and ectopic morphology.

So, ECG strip shows series of ectopic beats (a run of Vtach; the ectopic rhythm) followed by capture beats (normal configuration; the sinus rhythm) and then a gradual merging of the capture beats into the ectopic beats.

Avr algorithm

If the distance traveled on the Y axis in the initial 40ms of the QRS complex is smaller than that traveled in the terminal 40ms of the QRS complex, a VT is much more likelyUltrasimple Brugada criterion: RW to peak Time (RWPT)

In 2010 Joseph Brugada et al. published a new criterion to differentiate VT from SVT in wide complex tachycardias: the R wave peak time in Lead II[4].

They suggest measuring the duration of onset of the QRS to the first change in polarity (either nadir Q or peak R) in lead II. If the RWPT is 50ms the likelihood of a VT very high (positive likelihood ratio 34.8).

Ecg discussionRate : 180 ventricular rateRhtdym : regularAxis : normalP wave not clearly discernableQRS COMPLEX: Slurred wide complex of duration 200msecQS PATTERN in V1 to V4BRUGADAs criteriaStep 1: RS complex inV4 leadStep 2 : RS duration is 120msec All these favours VTAVR ALGORITMStep 1: intial r wave : absentStep 2: r wave is 50 msec This favours VTUltrasimple Brugada criterion: RW to peak Time (RWPT)Here RWPT IS 60msecThis favors VTOur ecg h/o MI V4 RS complex duration RS >100 msA-v dissociationAvr s/o vtRWPT > 50msAxis is normalNot typical vt LBB morphologyQrs duration .14 s with lbbbNon concordancePresence of RS complexFavours VTAgainst VTConclusion-diagnosisVENTRICULAR TACHYCARDIA WITH LBBB MORPHOLOGYCAD- OLD ANT.SEPTAL MI

A 26yrs old man presented to emergency with complaints of feeling of uneasiness , heaviness in chest, dyspnoea with no significant past history of any medical illnessO/EBP 80/60No P/CY/CL/ICT/LAP/EDEMA

CASE 2

DISCUSSION

Rate : 210 ventricular rateRhythm : not sinus P wave cant be discernableQRS COMPLEX : Wide ; duration is nearly 160 msecConcordance: NOFusion beats and AV dissociation : NO

Applying Brugada algorithmStep 1: rS complex presentStep 2: rS complex duration: here 80msecStep 3: av dissociation here absentStep 4 : morphological criteriaRBBB pattern is presentIn V1 : rSR patternIn V6 : height of S > R so R/S > 1All these finding favours that it is SVT with abberancy

AVR algorithm

Intial R wave in AVR : NOWave r = 40 msecNo notching in decending limb and no negative predominace of QRSVi < Vt All these favours SVT with abberancy

Ultrasimple Brugada criterion: RW to peak Time (RWPT)

HERE RWPT is 40msec in Lead IISo it is favours SVT with abberancy

PREVOSTBATELLIDISCOVERY OF DEFIBRILLATORDefibrillation was invented in1899by Prevost and Batelli, Twophysiologistsfrom University of Geneva, Switzerland. They discovered that small electric shocks could induce ventricular fibrillation in dogs, and that larger charges would reverse the condition.THANK YOU