Pseudo-Kussmaul's Sign in Atrioventricular Nodal Reentry Tachycardia: A Prospective, Cohort Study.

Aims: To study the respiratory variation of right atrial (RA) pressures at baseline and during atrioventricular nodal reentry tachycardia (AVNRT). Methods: Of the 23 patients screened, 16 participants with typical AVNRT were included in the study. After ensuring adequate hydration, baseline RA pressures were measured as the height of 'a' and 'v' waves. The patients were asked to take deep breaths, and the measurements were taken in both inspiration and expiration. Results: Of the 16 participants, 14(87.5%) showed a normal fall in the height of 'a' and 'v' waves with inspiration, 1(6.25%) showed no change and 1(6.25%) showed a rise in height at baseline, p <0.01. During induced AVNRT, the 'a' and 'v' wave heights increased in 8(50%), remained same in 6(37.5%) and showed a normal fall in 2(12.5%), p = 0.07 for 'a' waves and p = 0.09 for 'v' waves. When the magnitude and direction of change in 'a' and 'v' wave height at baseline was compared with AVNRT, it showed a significant difference with 13(81.25%) participants demonstrating positive Pseudo-Kussmaul's sign, p <0.01. Mean age was numerically higher in those with a more considerable inspiratory rise in RA pressures but was not statistically significant, χ2(2) = 3.1, p = 0.21. Conclusions: Pseudo-Kussmaul's sign does occur in a substantial number of patients during AVNRT. Clinical appreciation of this phenomenon is possible in half to three-fourth of patients, provided the mean RA pressures are low enough for the variation to be visible in the neck.

Incidence, clinical, electrophysiological characteristics and outcomes of patients with Wolff-Parkinson-White syndrome and atrial fibrillation.

AIMS AND OBJECTIVES: Atrial fibrillation (AF) with preexcitation can be life threatening. Our study evaluated the incidence, clinical features, electrophysiologic characteristics and outcomes of patients presenting with AF and fast ventricular rates associated with an antegrade conducting accessory pathway. METHODS: Hospital data of patients who had undergone electrophysiology study and radiofrequency ablation for AF and Wolff-Parkinson-White (WPW) syndrome was retrospectively evaluated over 10 years and prospective data was further collected over 1 year. Out of 2876 patients undergoing electrophysiology study, 320 patients had manifest preexcitation on ECG. Forty one patients who had presented with AF and fast ventricular rates were included in the study. RESULTS: Forty one (12.8%) patients out of 320 patients of WPW syndrome patients presented with AF and fast ventricular rates. Mean age of presentation was 38.5 ± 12.3 yrs. Twenty nine (72.5%) were male. Most common presenting features were palpitations, presyncope and syncope. Twenty eight (71.1%) patients were electrically cardioverted on presentation, of which two patients having narrow complex tachycardia, when given adenosine, developed AF and fast ventricular rates and had to be electrically cardioverted. Intravenous amiodarone converted AF to sinus rhythm in 11 (28.9%) patients. Right postero-septal pathway (33.3%) followed by coronary sinus epicardial pathway (22.9%) were the most commonly located pathways associated with AF. Five (12.2%) patients had multiple pathways. CS diverticulum was seen in 6 (14.7%) patients. Ablation was done during AF in 6 (14.7%) patients. All except one had immediate successful ablation. One patient had a recurrence of preexcitation on follow up and successfully ablated during redo procedure. CONCLUSION: AF with WPW syndrome is not uncommon. AF is commonly associated with posteriorly located accessory pathways, CS diverticulum and multiple pathways. Radiofrequency ablation has good outcomes.

Response of narrow QRS tachycardia in a patient with surgical closure of atrial septal defect to atrial overdrive pacing: What is the mechanism?

A 57-year old woman who had pericardial patch closure of ostium secundum atrial septal defect (ASD) at the age of 23 years presented with shortness of breath. Her echocardiogram showed no residual ASD, good biventricular function and normal pulmonary artery pressures.

Interesting case of dual tachycardia in a patient with surgical closure of atrial septal defect.

A 34-year-old gentleman, who had undergone pericardial patch closure of ostium secundum atrial septal defect (ASD) at 8 years of age, was evaluated for shortness of breath. Electrocardiogram revealed typical atrial flutter with varying atrioventricular conduction. Echocardiogram showed no residual ASD or pulmonary hypertension and good biventricular function. He was taken for an electrophysiological study with the intention of radiofrequency ablation of the typical flutter.

Interesting case of narrow QRS tachycardia with atrioventricular dissociation.

A 30-year-old man with no structural heart disease has been evaluated for paroxysmal palpitation with documented regular narrow QRS tachycardia that has not responded to intravenous adenosine. Surface electrocardiogram has not shown any pre-excitation. He has been taken for an electrophysiology study after informed consent. Diagnostic catheters were placed at the coronary sinus, His bundle region, and right ventricle. During catheter manipulation a regular narrow QRS tachycardia with incomplete right bundle branch block morphology and normal QRS axis similar to the clinical tachycardia got induced. No other tachycardia was induced. What is the mechanism of tachycardia?

Narrow QRS tachycardia with extreme rightward axis. What is the mechanism?

A 25 year old lady presented with palpitation to the emergency department. Her pulse rate was 210 beats per minute. She was hemodynamically stable with a blood pressure of 100/60 mm Hg. 12 lead surface electrocardiogram (ECG) was recorded during the presentation (Fig. 1) and rhythm strip (Fig. 2A) during administration of IV adenosine. What is the likely diagnosis?