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Rhythm Disorders

Supraventricular Tachycardia Following Mitral Valve Surgery

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Cardiology

Published Online: September 7, 2022

JAMA Cardiology Clinical Challenge

Article Information and Disclosures

Vincenzo Carbone, MD¹;

Giovanni Carbone, MD²;

Antonio Cassese, MD¹

Author Affiliations

¹Outpatient Cardiology, Naples, Italy
²Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy

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A man in his mid-50s with a history of mitral valve repair presented to the emergency department with complaints of recent-onset palpitation within the last hour. On physical examination, the patient showed a rhythmic tachycardia with a rate of 178 beats/min and blood pressure of 130/80 mm Hg. The 12-lead electrocardiogram (ECG) revealed a regular tachycardia with a rate of 178 beats/min; no obvious P waves were recognizable (Figure 1A). The QRS complexes displayed 2 different morphologies occurring with a definite allorhythmic distribution: pairs of beats exhibiting complete right bundle branch block (RBBB) and QRS duration of 140 milliseconds followed by a third beat with normal configuration and QRS duration of 70 milliseconds. This trigeminal variation in intraventricular conduction occurred without any change in cycle length and was maintained. Adenosine administration quickly slowed the ventricular rate allowing recognition of an atrial tachycardia with a rate of 178/min and a 2:1 atrioventricular (AV) ratio (Figure 1B).

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Atypical atrial flutter with RBBB aberration and conduction improvement every third beat resulting from concealed type I (Wenckebach) second-degree block in the right bundle branch with 3:2 ratio

C. Start treatment with low-molecular-weight heparin and amiodarone

The atrial rate during adenosine administration was identical to the ventricular rate during tachycardia, implying that the arrhythmia in Figure 1A reflects an atrial tachycardia with 1:1 AV conduction. The medical history strongly suggests a macroreentrant circuit (macroreentrant atrial tachycardia, also called atypical atrial flutter) developing around the atriotomy scar related to mitral valve surgery, possibly a left-sided atrial flutter such as mitral annular flutter. The R-R interval prolongation due to the shift from 1:1 to 2:1 AV ratio restored the normal right bundle branch conduction resulting in narrow QRS complexes. This supports an intermittent phase 3 RBBB. The most challenging issue in the tracing on presentation is the periodic disappearance of the RBBB aberration. The key to the correct diagnosis is the unexpected normalization of the QRS morphology occurring periodically, every third beat, despite constant cycle lengths.¹^- 4

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Article Information

Corresponding Author: Vincenzo Carbone, MD, Outpatient Cardiology, via Europa, 84 S Giuseppe Vesuviano, Naples 80047, Italy (carbovincenzo61@gmail.com).

Published Online: September 7, 2022. doi:10.1001/jamacardio.2022.2902

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

Gallagher JJ , Damato AN , Varghese PJ , Caracta AR , Josephson ME , Lau SH . Alternative mechanisms of apparent supernormal atrioventricular conduction. Am J Cardiol. 1973;31(3):362-371. doi:10.1016/0002-9149(73)90269-5 PubMed Google Scholar Crossref

Josephson ME . Miscellaneous phenomena related to atrioventricular conduction. In: Josephson’s Clinical Cardiac Electrophysiology: Techniques and Interpretations. 5th ed. Wolters Kluwer; 2016.

Rosenbaum MB , Nau GJ , Levi RJ , Halpern MS , Elizari MV , Lazzari JO . Wenckebach periods in the bundle branches. Circulation. 1969;40(1):79-86. doi:10.1161/01.CIR.40.1.79 PubMed Google Scholar Crossref

Friedberg HD , Schamroth L . Concealed Wenckebach phenomena in the left bundle-branch. Br Heart J. 1972;34(4):370-373. doi:10.1136/hrt.34.4.370 PubMed Google Scholar Crossref

Brugada J , Katritsis DG , Arbelo E , et al; ESC Scientific Document Group. 2019 ESC guidelines for the management of patients with supraventricular tachycardia. Eur Heart J. 2020;41(5):655-720. doi:10.1093/eurheartj/ehz467 PubMed Google Scholar Crossref

Hindricks G , Potpara T , Dagres N , et al; ESC Scientific Document Group. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42(5):373-498. doi:10.1093/eurheartj/ehaa612 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.