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Development of malignant ventricular arrhythmias in a young male with WPW pattern.
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MedLine Citation:
PMID:  20376188     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
In Wolff-Parkinson-White Syndrome (WPW), presence of accessory pathways causes various tachyarrhythmias that lead to different symptoms and clinical conditions in patients. Atrial fibrillation is observed in about 20-30% of this group of patients. Life threatening malignant ventricular arrhythmias and sudden cardiac deaths are observed in patients having rapid conduction in accessory pathways and short antegrade refractory periods (<250 msn). We present a WPW syndrome case that presented to the emergency service with narrow QRS tachycardia and later developed malignant ventricular arrhythmia.
Authors:
Alim Erdem; Nihat Madak; Ahmet Yilmaz; Osman Can Yontar; Hasan Yucel; Ibrahim Gul; Izzet Tandogan
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Publication Detail:
Type:  Journal Article     Date:  2010-04-01
Journal Detail:
Title:  Indian pacing and electrophysiology journal     Volume:  10     ISSN:  0972-6292     ISO Abbreviation:  Indian Pacing Electrophysiol J     Publication Date:  2010  
Date Detail:
Created Date:  2010-04-08     Completed Date:  2010-05-24     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101157207     Medline TA:  Indian Pacing Electrophysiol J     Country:  India    
Other Details:
Languages:  eng     Pagination:  195-200     Citation Subset:  -    
Affiliation:
Cardiology Department, Sivas Public Hospital, Kars, Turkey. dralimerdem@gmail.com
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Indian Pacing Electrophysiol J
Journal ID (publisher-id): Indian Pacing Electrophysiol J
ISSN: 0972-6292
Publisher: Indian Heart Rhythm Society
Article Information
Copyright: ? 2010 Erdem et al.
open-access:
collection publication date: Year: 2010
Electronic publication date: Day: 01 Month: 4 Year: 2010
Volume: 10 Issue: 4
First Page: 195 Last Page: 200
ID: 2847871
PubMed Id: 20376188
Publisher Id: ipej100195-00

Development of Malignant Ventricular Arrhythmias in a Young Male with WPW Pattern
Alim Erdem1
Nihat Madak2
Ahmet Yilmaz3
Osman Can Yontar3
Hasan Yucel3
Ibrahim Gul3
Izzet Tandogan3
1Cardiology Department, Sivas Public Hospital, Kars, Turkey
2Cardiology Department, Malatya Public Hospital, Malatya, Turkey
3Cardiology Department, School of Medicine, Cumhuriyet University, Sivas, Turkey
Correspondence: Address for correspondence: Dr. Alim Erdem, Cardiology Department, Sivas Public Hospital, Kars, Turkey. E-mail: dralimerdem@gmail.com

Case Report

A 32 years old male with no previous cardiac evaluation and clinical complaints presented to the emergency service with palpitation. Due to narrow QRS complex tachycardia, emergency service physicians (Figure 1) administered intravenous verapamil for rate control. Meanwhile, the patient developed atrial fibrillation with wide QRS and high ventricular response (Figure 2) and then ventricular fibrillation. Normal sinus rhythm was achieved after multiple defibrillations (220 joule, Biphasic). Hemodynamic parameters and respiration were stabilized. 12 lead ECG showed characterstic delta waves and short PR interval. (Figure 3). Given these findings, the case was diagnosed as Wolff-Parkinson-White (WPW) syndrome. His physical examination, biochemical parameters and echocardiography were normal. As the case was a WPW syndrome case and as malignant ventricular arrhythmia and cardiopulmonary arrest developed due to atrial fibrillation, he was assigned to electrophysiological (EPS) study. In our case, whose orthodromic tachycardia was induced again during EPS (Figure 4). An accessory pathway was found at left anterior localization based on intracardiac findings, and successful ablation was achieved in the same session (Figure 5). On the surface ECG, it was observed that PR interval was back to normal and delta wave was no more present. The case was asymptomatic and his ECG was normal during his controls at 1st and 6th months.


Discussion

WPW syndrome is a clinical entity characterized by presence of an electrical signaling accessory pathway between atrium and ventricular that may cause tachyarrhythmia's sometimes and sudden cardiac death. Studies have shown that SCD occurs at the rate of 0.15% per year in patients with WPW. These deaths are caused by atrial fibrillation with rapid ventricular response that leads to ventricular fibrillation (VF) [1,2].

The most frequently encountered tachycardia in WPW syndrome is the reentrant tachycardia. The degeneration of reciprocating tachycardia to atrial fibrillation is not uncommon [3]. It has been estimated that atrial fibrillation (AF) is observed in approximately one third of WPW patients. AF may cause fatal arrhythmias in WPW syndrome [4]. Sudden death occurs due to transmission of AF into VF with a rapid ventricular response over one or more accessory pathways with a short antegrade refractory period [5]. The first presentation of some WPW patients with asymptomatic clinical course could be due to ventricular fibrillation [6].

Risks factors for sudden death in WPW are presence of more than one AP, development of AVRT along with AF and the shortest preexcitation RR interval less than 260 msn [1,2,7]. Development of atrial fibrillation as a result of IV verapamil administration for rate control in reciprocal tachycardia is not rare [8]. Straberg et al reported 3 cases presented with atrial fibrillation and rapid ventricular response with wide preexcitation QRS, all of whom received intravenous verapamil (5-10 mg); and they stated that one of the patients developed ventricular fibrillation requiring several defibrillations, the other had hemodynamic deterioration and the last one had a marked increment in the ventricular response. When verapamil is used to treat reentrant supraventricular tachycardia complicating the WPW syndrome, the electrophysiologic effects of verapamil on accessory pathway conduction during atrial fibrillation become critical. Patients with WPW syndrome have a higher incidence of atrial fibrillation than the general population [10,11]. We think that verapamil administered for rhythm and rate control at emergency service induced AF with wide QRS and consequent VF development in our case too. Antz et al. stated that patients with WPW syndrome who had undergone CPR for malignant ventricular function had normal left ventricular function at echocardiography and no ECG abnormalities and ablation of their accessory pathways prevented cardiac arrest recurrences [12]. Catheter ablation is suggested for patients resuscitated from VF or for patients at high risk for clinical atrial fibrillation with a rapid ventricular response [13].

As a result, Using AV node suppressive medicines in patients with WPW syndrome may cause atrial fibrillation followed by development of fatal cardiac arrhythmias. We believe that it is important to acquaint all the clinicians, especially the emergency service and ambulance physicians who are the first to face SVT patients in daily practice, with this issue.


References
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Sethi KK,et al. J Assoc Physicians IndiaYear: 2007551018368860
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Wellens HJ,et al. Wolff-Parkinson-White Syndrome and atrial fibrillation: relation between refractory period of accessory pathway and ventricular rate during atrial fibrillationAm J cardiolYear: 1974347774432808
Antz M,et al. Risk of sudden death after successful accessory atrioventricular pathway ablation in resuscitated patients with Wolff-Parkinson-White syndromeJ Cardiovasc ElectrophysiolYear: 20021323111942588
Zipes DP,et al. Guidelines for clinical intracardiac electrophysiological and catheter ablation procedures. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures), developed in collaboration with the North American Society of Pacing and ElectrophysiologyJ Am Coll CardiolYear: 1995265557608464

Article Categories:
  • Case Report

Keywords: WPW syndrome, life threatening arrhythmias.

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