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Bigeminy, aberrancy, and atrial tachycardia in a patient with palpitations: The Importance of 12-lead electrocardiography
Dr Jonathan P Piccini, MD, MHS, FACC, FAHA, FHRS
Duke University Medical Center, Duke Clinical Research Institute, Durham, USA
A 29-year-old woman presented for evaluation due to a long-standing history of palpitations. She recalled experiencing palpitations for over 15 years, including during participating in high school sporting events. Her palpitations lasted from minutes to hours. Vagal maneuvers would improve but not eliminate her symptoms. Beta-blocker and calcium channel blockade did not improve her symptoms. Her past medical history was unremarkable other than a diagnosis of frequent PVCs.
Methods & results
The physical examination was normal, and her echocardiogram revealed no evidence of structural heart disease. Her 12-lead electrocardiogram in clinic revealed atrial bigeminy with evidence of right bundle branch aberrancy (Figure 1). The sinus P-wave was positive/negative in lead V1. In contrast, the ectopic P-wave was positive in V1 and across the precordium. The vector was consistent with origin in the posterior left atrium. Ambulatory monitoring demonstrated a narrow complex tachycardia at 200 beats per minute with 1:1 conduction as well as periods of wide complex tachycardia consistent with aberrancy. Due to her symptomatic supraventricular tachycardia, she underwent an electrophysiology study which revealed easy induction of a rapid atrial tachycardia. The tachycardia was mapped to the inferior portion of the posterior wall of the left atrium. Radiofrequency ablation at the site of earliest activation rendered her atrial tachycardia uninducible and she remains symptom-free 6 months after her ablation.
This case of supraventricular tachycardia was due to a left atrial tachycardia. While the case is not unusual, it does highlight the importance of 12-lead electrocardiography in the diagnosis and management of supraventricular tachycardia. The 12-lead electrocardiogram provided important diagnostic information regarding her bigeminal rhythm and wide complex tachycardia and led to a diagnosis of left atrial PAC with right bundle branch aberration. While 12-lead electrocardiograms are not easily obtained in quick fashion outside of medical facilities, further evolution of wearable technologies may make 12-lead electrocardiograms easier to obtain and may further improve the diagnosis of supraventricular tachycardia.
Figure 1. 12-lead electrocardiogram obtained during mild symptoms. The electrocardiogram reveals atrial bigeminy with a sinus beat followed by a premature atrial beat with right bundle branch aberrancy. The comparison of the P-wave morphology between the sinus beat and the ectopic P-waves suggested that the premature atrial beats were originating in the posterior left atrium.
Figure 2. Electroanatomic map displaying earliest activation of left atrial tachycardia emanating from the low posterior wall between the left inferior and right inferior veins. This atrial tachycardia was successfully eliminated with radiofrequency ablation.