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• W2891385293 abstract "HomeCirculationVol. 138, No. 11Letter by Milicevic Regarding Article, “Wide QRS Complex Tachycardia: What the Algorithms Fear” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Milicevic Regarding Article, “Wide QRS Complex Tachycardia: What the Algorithms Fear” Goran Milicevic, MD, PhD Goran MilicevicGoran Milicevic Intensive Cardiology Department, Clinical Hospital Sveti Duh, Zagreb, Faculty of Medicine, University of Osijek, Croatia. Search for more papers by this author Originally published10 Sep 2018https://doi.org/10.1161/CIRCULATIONAHA.118.035641Circulation. 2018;138:1172–1173To the Editor:I read with interest the article by Vera and coworkers1 describing the case of a wide QRS complex tachycardia. They presented a very important topic, interesting for a wide cardiology and emergency medicine audience, and offered diagnostic solutions for their ECG. However, when they suggest the diagnosis of aberrantly conducted atrial flutter instead of a simplified conclusion of a ventricular tachycardia, I could not agree with that so easily. Although they might be right, I would like to see the results of an electrophysiological study as a proof for that thesis.Namely, regardless of the existence of an accessory pathway and the atrial flutter waves visible during the wide QRS complex tachycardia, it is still possible that the tachycardia was ventricular. Although all morphological criteria are not fulfilled and RR intervals are relatively irregular, a nonreentrant tachycardia from the left ventricular inferoseptal area (which the echocardiogram lacks) is not excluded in that 70-year-old patient. Atrial and ventricular activities are close to a regular relationship, but the RR intervals are still too irregular for conducted atrial flutter, even if conducted with Wenckebach phenomenon, suggesting that it was isorhythmic dissociation.Hypothetically, it may have been even a far more complex tachyarrhythmia, for example, right atrial flutter and simultaneous fibrillation or other irregular tachycardia from the left atrium2 (the latter hidden on the surface ECG), with right atrial flutter conducted through the main conduction system (with narrow QRS complexes) and left atrial tachyarrhythmia intermittently conducted through the accessory pathway (in the form of wide QRS complex tachycardia).So, to complete the case, a surface ECG of a tachyarrhythmia induced by left atrial pacing and conducted through the posterior left-sided accessory pathway (with the additional use of procainamide), resulting in a record of the same or at least similar morphology to that presented in Figures 1 and 2, along with a simultaneous intracardiac electrogram, has to be shown as evidence of aberrantly conducted atrial flutter.However, the topic, diagnosis of a wide QRS complex tachycardia, is highly important for emergency situations in a daily practice and for routine electrophysiology examinations, which have to be elucidated by various clinical examples, among which the one presented here was very illustrative.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circReferences1. Vera A, Cecconi A, Nogales-Romo MT, de la Cuerda F, Salamanca J, Jimenez-Borreguero LJ, Alfonso F. Wide QRS complex tachycardia: what the algorithms fear.Circulation. 2018; 137:1407–1409. doi: 10.1161/CIRCULATIONAHA.118.033936LinkGoogle Scholar2. Zipes DP, Dejoseph RL. Dissimilar atrial rhythms in man and dog.Am J Cardiol. 1973; 32:618–628.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails September 11, 2018Vol 138, Issue 11 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.035641PMID: 30354388 Originally publishedSeptember 10, 2018 PDF download Advertisement SubjectsArrhythmiasElectrophysiology" @default.
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