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Atrioventricular 2:1-conduction via an accessory pathway during left atrial flutter unmasking WPW syndrome: a case report

Atrioventricular 2:1-conduction via an accessory pathway during left atrial flutter unmasking WPW... BackgroundImplantable cardioverter defibrillators (ICDs) are most effective in treating sudden cardiac death. However, accurate diagnostic workup of broad complex tachycardia is crucial to ensure correct indication for ICD treatment and to avoid unnecessary invasive treatment and device-associated morbidity.Case summaryWe present a case of atypical atrial flutter with 2:1 atrioventricular (AV) conduction via a left-posterior accessory pathway (AP), leading to the diagnosis of Wolff-Parkinson-White (WPW) syndrome. Upon admission, the 72-year-old patient showed a regular broad complex tachycardia with superior axis and positive concordance in precordial leads, suggestive of either ventricular tachycardia (VT), antidromic AV re-entrant tachycardia (AVRT), or supraventricular tachycardia with antegrade conduction via a left-posterior AP. Interrogation of the two-chamber ICD, which was very likely implanted unjustified in a peripheral clinic before, revealed atrial flutter with 2:1 AV conduction. Remarkably, after the restoration of sinus rhythm, no classic echocardiogram (ECG) criteria for preexcitation syndrome were detected. An invasive electrophysiological study proved the diagnosis of a bidirectionally conducting, left-posterior AP, which was successfully ablated.DiscussionDifferential diagnosis of broad complex tachycardia with superior axis and positive concordance of chest leads consists of i) VT with a left ventricular exit at the posterior mitral annulus, ii) antidromic AVRT involving a left-posterior AP, and iii) supraventricular tachycardia predominantly conducted via a left-posterior AP. The absence of classic ECG criteria for preexcitation syndrome does not rule out AP sufficiently, highlighting the importance of minimal surface-ECG preexcitation criteria. In the case of detection of minimal surface-ECG preexcitation criteria, administration of adenosine rules out or proves the existence of an AP noninvasively and cost-effectively. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal - Case Reports Oxford University Press

Atrioventricular 2:1-conduction via an accessory pathway during left atrial flutter unmasking WPW syndrome: a case report

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References (5)

Publisher
Oxford University Press
Copyright
© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.
eISSN
2514-2119
DOI
10.1093/ehjcr/ytac250
Publisher site
See Article on Publisher Site

Abstract

BackgroundImplantable cardioverter defibrillators (ICDs) are most effective in treating sudden cardiac death. However, accurate diagnostic workup of broad complex tachycardia is crucial to ensure correct indication for ICD treatment and to avoid unnecessary invasive treatment and device-associated morbidity.Case summaryWe present a case of atypical atrial flutter with 2:1 atrioventricular (AV) conduction via a left-posterior accessory pathway (AP), leading to the diagnosis of Wolff-Parkinson-White (WPW) syndrome. Upon admission, the 72-year-old patient showed a regular broad complex tachycardia with superior axis and positive concordance in precordial leads, suggestive of either ventricular tachycardia (VT), antidromic AV re-entrant tachycardia (AVRT), or supraventricular tachycardia with antegrade conduction via a left-posterior AP. Interrogation of the two-chamber ICD, which was very likely implanted unjustified in a peripheral clinic before, revealed atrial flutter with 2:1 AV conduction. Remarkably, after the restoration of sinus rhythm, no classic echocardiogram (ECG) criteria for preexcitation syndrome were detected. An invasive electrophysiological study proved the diagnosis of a bidirectionally conducting, left-posterior AP, which was successfully ablated.DiscussionDifferential diagnosis of broad complex tachycardia with superior axis and positive concordance of chest leads consists of i) VT with a left ventricular exit at the posterior mitral annulus, ii) antidromic AVRT involving a left-posterior AP, and iii) supraventricular tachycardia predominantly conducted via a left-posterior AP. The absence of classic ECG criteria for preexcitation syndrome does not rule out AP sufficiently, highlighting the importance of minimal surface-ECG preexcitation criteria. In the case of detection of minimal surface-ECG preexcitation criteria, administration of adenosine rules out or proves the existence of an AP noninvasively and cost-effectively.

Journal

European Heart Journal - Case Reports – Oxford University Press

Published: Jun 28, 2022

Keywords: WPW syndrome; Left-posterior accessory pathway; Atypical atrial flutter; 2:1 AV conduction; Broad complex tachycardia; Case report

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