A94-year-old asymptomatic woman was sent to the Emergency Room after being found to have an irregular pulse. An ECG showed a wide-complex tachycardia with right bundle-branch block morphology with a ventricular rate of 120 to 150 bpm. Her hemodynamics remained otherwise stable. The tachycardia persisted despite trials of adenosine, diltiazem, lidocaine, and procainamide. Because it was not clear whether this rhythm was ventricular tachycardia or a supraventricular tachycardia with aberrant conduction, we placed a transesophageal lead to further define the rhythm. The transesophageal lead demonstrated marked disparity between the atrial and ventricular rates, with the ventricular rate exceeding the atrial rate, thus confirming the diagnosis of ventricular tachycardia. She was treated with electrical cardioversion and returned to normal sinus rhythm.
In some cases, differentiating ventricular tachycardia from supraventricular tachycardia when confronted with a wide-complex tachycardia can be quite difficult, yet it is obviously imperative for the clinical management of the patient. The placement of a transesophageal lead, which can be done quite easily at the bedside, can be quite helpful in clarifying the issue.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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