Indian Pacing Electrophysiol. J.

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Indian Pacing Electrophysiol. J. 2012;12(2):65-68           Case Report

Bidirectional Ventricular Tachycardia: A Hallmark of Catecholaminergic Polymorphic Ventricular Tachycardia

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Francisco Femenia1, MD; Raimundo Barbosa-Barros2, MD; Stela Vitorino Sampaio2, MD; Mauricio Arce1, MD; Andres Perez-Riera3, MD, PhD;  Adrian Baranchuk4, MD, FACC


1
Arrhythmia Unit. Cardiology Department. Hospital Espanol de Mendoza. Argentina
2Coronary Center. Hospital de Messejana “Dr. Carlos Alberto Studart Gomes”. Fortaleza, Ceara. Brazil
3Faculdade de Medicina do ABC. Fundacao do ABC. Santo Andre, Sao Paulo. Brazil
4Heart Rhythm Service. Queen's University. Kingston, Ontario. Canada

Address for Correspondence: Dr. Francisco Femenía. Av. San Martín 965. Godoy Cruz. Mendoza. Argentina. E-mail: femeniafavier/at/hotmail.com

Abstract

Catecholaminergic polymorphic ventricular tachycardia is a familial cardiac arrhythmia that is related to RYR2 or CASQ2 gene mutation. It occurs in patients with structurally normal heart and causes exercise-emotion triggered syncope and sudden cardiac death. We present a 13 year-old girl with recurrent episodes of exercise-related syncope and prior history of sudden death in a first degree relative.

Keywords: bidirectional tachycardia; ventricular tachycardia; catecholaminergic polymorphic ventricular tachycardia; syncope; sudden cardiac death
           
A 13-year-old girl with no cardiovascular history presented for evaluation of recurrent episodes of exercise-related syncope and prior history of sudden death in a first degree relative. The 12- lead electrocardiogram (ECG) at rest was normal and an echocardiogram confirmed a structurally normal heart. A 24-hour Holter monitoring (Figure 1, left panel) during physical activity showed the classic electrocardiographic manifestation of catecholaminergic polymorphic ventricular tachycardia (CPVT): bidirectional ventricular tachycardia (BVT), two alternating QRS complexes morphologies with different polarity (X and Y, Figure 1 right panel) with an XY interval of 240 ms and YX interval of 280 ms. It may be necessary to conduct a 12-lead ECG to confirm if those polarities represented right bundle branch block and left bundle branch block respectively. The BVT presented regular X-X and Y-Y intervals both at 520 ms. According to the classification originally proposed by Scherf and Kisch, the BVT presented here is a Type II BVT, defined by a regular and fixed alternation of short and long intervals.[1,2]



Figure 1. Left Panel: 24-Hour Holter monitoring. During physical activity, BVT is precipitated by ventricular bigeminy degenerating into polymorphic ventricular tachycardia and ventricular fibrillation. Right Panel: amplification of a segment of the 24-hour Holter monitoring depicting alternating QRS complex morphologies with different polarities, characteristic features of BVT.

This tachycardia suddenly degenerated into self-limiting polymorphic ventricular tachycardia and ventricular fibrillation (Figure 1, left panel), and normal sinus rhythm resumed upon spontaneous cessation of ventricular fibrillation. The resting 12-lead ECG was normal after the event. (Figure 2)



Figure 2. Normal resting 12-lead electrocardiogram

The patient was treated with propanolol 120 mg/day. During a control exercise stress test the patient presented again with CPVT symptomatic by syncope. An implantable automatic cardioverter defibrillator was implanted (PRIZM DR, Guidant, MN, USA). Genetic screening was not performed at the time of writing this report.

During a ten year follow-up, the patient presented with three episodes of polymorphic ventricular tachycardia requiring ICD shocks. Propranolol dose was increased (160 mg/day) and the patient remained asymptomatic for the last two years.              
                                                                                                                        
CPVT is a rare but highly malignant (syncope or sudden cardiac death) genetic disease related to the mutation of cardiac ryanodine receptor gene (RYR2) or calsequestrin 2 gene (CASQ2), leading to an increase in intracellular Ca++ concentration, resulting in arrhythmia due to a cascade of delayed after depolarization and triggered activity [3-6], and the four distinguishing features of CPVT have subsequently been described by Coumel et al [7]: 1) normal resting electrocardiogram; 2) exercise- or emotion-induced severe ventricular tachycardia; 3) a typical pattern of bidirectional ventricular tachycardia; and 4) a structurally normal heart.

BVT has been described in a variety of clinical settings including digitalis toxicity, herbal aconite poisoning, hypokalemic periodic paralysis, myocarditis, coronary artery disease, metastatic cardiac tumors, non-ischemic dilated cardiomyopathy, Anderson-Tawil syndrome, and at the same time, has been recognized as a hallmark of CPVT.[8]  It is usually triggered by exercise or emotional stress. It can be precipitated by premature ventricular contractions or ventricular bigeminy. As in this case, it can degenerate into polymorphic ventricular tachycardia and ventricular fibrillation.

The treatment is directed to suppress adrenergic activity, therefore beta-blockers are the most important drug in the treatment of CPVT. Beta-blockers are effective for the acute phase and maintenance treatment. However, if symptoms recur, ICD should be considered. Flecainide is also part of the armamentarium to treat this infrequent disease [9].

References

1. Siegal D, Quinlan C, Parfrey B, Simpson CS, Redfearn DP, Baranchuk A. Type II bidirectional ventricular tachycardia as a mechanism of termination of sustained ventricular tachycardia. J Cardiovasc Electrophysiol 2009; 20: 345-6

2. Schamroth L. Ventricular Tachycardia and Ventricular Flutter. In: The Disorders of Cardiac Rhythm: Blackwell Science Ltd.; London, 1980; chapter 23, pp.107-115.

3. Priori SG, Napolitano C, Memmi M, Colombi B, Drago F, Gasparini M et al. Clinical and molecular characterization of patients with catecholaminergic polymorphic ventricular tachycardia. Circulation 2002; 106: 69–74.

4. Ylanen K, Poutanen T, Hiippala A, Swan H, Korppi M. Catecholaminergic  polymorphic ventricular tachycardia. Eur J Pediatr 2010; 169: 535–542.

5. Femenia F, Perez Riera AR. Estratificacion del riesgo en las canalopatias congenitas. Revista Iberoamericana de Arritmología 2011; doi: 10.5031/v1i2.RIA10119.

6. Baher AA, Uy M, Xie F, Garfinkel A, Qu Z, Weiss JN. Bidirectional ventricular tachycardia: ping pong in the His-Purkinje system. Heart Rhythm 2011; 8: 599-605.

7. Coumel P, Fidelle J, Lucet V, Attuel P, Bouvrain Y. Catecholaminergic-induced severe ventricular arrhythmias with Adams-Stokes syndrome in children: report of four cases. Br Heart J 1978; 40: 28-37.

8. Sonmez O, Gul EE, Duman C, Duzenli MA, Tokac M, Cooper J. Type II bidirectional ventricular tachycardia in a patient with myocardial infarction. J Electrocardiol 2009, 42: 631-632.

9. Biernacka EK, Hoffman P. Efficacy of flecainide in a patient with catecholaminergic polymorphic ventricular tachycardia. Europace 2011; 13: 129-30.

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