eMedicine Specialties > Cardiology > Arrhythmias
Ventricular Tachycardia: Multimedia
Updated: Oct 24, 2008
Multimedia
 | Media file 1: This is a rapid monomorphic ventricular tachycardia (VT), 280 beats per minute, associated with hemodynamic collapse. This tracing was obtained from a patient with severe ischemic cardiomyopathy during an electrophysiologic (EP) study. The rhythm later converted to sinus with a single external shock. This patient had an atrial rate of 72 beats per minute (measured with intracardiac electrodes, not shown). Although ventriculoatrial dissociation (faster V rate than A rate) is diagnostic of VT, the surface ECG findings are only present approximately 20% of the time. In this tracing, the ventricular rate is simply too fast for P waves to be observed. VT with cycle lengths from 200-240 ms is often termed ventricular flutter. |
 | Media file 2: This is a slow monomorphic ventricular tachycardia (VT), 121 beats per minute, from a patient with an old inferior wall myocardial infarction and well-preserved left ventricular function (ejection fraction [EF] 55%). He presented with symptoms of palpitation and neck fullness. Note the ventriculoatrial dissociation, most obvious in V2 and V3. Slower VT rates and preserved left ventricular (LV) function are associated with a better long-term prognosis. |
 | Media file 3: Repetitive monomorphic ventricular tachycardia (VT) from an asymptomatic 45-year-old female wind surfer with a structurally normal heart. This ECG pattern is typical for idiopathic VT arising from the right ventricular outflow tract. This rhythm is often exertional and, unlike ischemic VT, suppressed by beta blockade or verapamil. The prognosis is good, with the following exceptions: (1) sudden death may be seen if right ventricular dysplasia or exceptionally rapid VT is encountered, and (2) occasionally, patients with incessant VT develop congestive heart failure due to tachycardia-induced cardiomyopathy or frequent ectopy. The cardiomyopathy resolves when the tachycardia is treated. |
 | Media file 4: At first glance, this tracing suggests rapid, polymorphic ventricular tachycardia (VT). This is actually sinus rhythm with a premature atrial complex and superimposed lead motion artifact. The hidden sinus beats can be observed by using calipers to march backwards from the final 2 QRS complexes. This artifact can be generated easily with rapid arm motion (eg, brushing teeth) during telemetry monitoring. |
 | Media file 5: Torsade de pointes. This is a polymorphic ventricular tachycardia (VT) associated with resting QT-interval prolongation. In this case, it was caused by the potassium channel blocker, sotalol. This rhythm is also observed in families with mutations affecting certain cardiac ion channels. |
 | Media file 6: Preexcited atrial fibrillation. This patient has an accessory atrioventricular connection. Atrial fibrillation has been induced. Conduction over the accessory pathway results in a wide QRS complex, mimicking ventricular tachycardia (VT). |
 | Media file 7: Curative ablation of ventricular tachycardia (VT) This patient has VT in the setting of an ischemic cardiomyopathy. His VT was induced in the electrophysiology laboratory, and an ablation catheter was placed at a critical zone of slow conduction within the VT circuit. Radiofrequency (RF) energy is applied to the tissue through the catheter tip, and VT terminates when the critical conducting tissue is destroyed. |
 | Media file 8: Ventricular pacing at 120 beats per minute Newer pacemakers use bipolar pacing. If the smaller pacing stimulus artifact is overlooked, an erroneous diagnosis of ventricular tachycardia (VT) may result. Because leads are most commonly placed in the right ventricular apex, paced beats will have left bundle branch block (LBBB) morphology with an inferior axis. Causes of rapid pacing include (1) tracking of an atrial tachycardia in DDD mode, (2) rapid pacing due to rate response being activated, and (3) endless loop tachycardia. Application of a magnet to the pacemaker will disable sensing and allow further diagnosis. |
 | Media file 9: Supraventricular tachycardia (SVT) with aberrancy This is a patient with a structurally normal heart who has a normal resting ECG. This rhythm is an orthodromic reciprocating tachycardia with a rate-related left bundle branch block. Note the relatively narrow RS intervals in the precordial leads. |
 | Media file 10: Termination of ventricular tachycardia (VT) with overdrive pacing. This patient has a reentrant VT, which is terminated automatically by pacing from an implantable cardioverter-defibrillator (ICD). |
 | Media file 11: This is a posteroanterior view of a right ventricular endocardial activation map during ventricular tachycardia in a patient with a prior septal myocardial infarction. Earliest activation is recorded in red; late activation shows as blue to magenta. Fragmented low amplitude diastolic local electrograms were recorded adjacent to the earliest (red) breakout area, and local ablation in this scarred zone (red dots) resulted in termination and noninducibility of this previously incessant arrhythmia. |
 | Media file 12: Monomorphic ventricular tachycardia. |
 | Media file 13: Polymorphic ventricular tachycardia. |
 | Media file 14: This ECG is from a 32-year-old female with recent-onset congestive heart failure and syncope. |
 | Media file 15:
This ECG is from a 48-year-old male with wide
complex tachycardia during treadmill stress test. Any wide
complex tachycardia tracing should raise the possibility of VT,
but closer scrutiny confirms left bundle branch block
conduction of a supraventricular rhythm. Starting with the
Brugada criteria, RS complexes are apparent in the precordium
(V2-V4), and the interval from
the R wave onset to the deepest part of the S wave is <100
msec in each of these leads. Ventriculoatrial dissociation is
not seen. See Brugada et al (1991) for details of additional
morphologic criteria. The Vereckei criteria (2008) are based solely upon aVR, which shows no R wave, an initial q wave width <40 ms, and no initial notching in the q wave. The last criterion by Vereckei et al examines the slope of the initial 40 ms of the QRS versus the terminal 40 ms of the QRS complex in aVR. In this case, the initial downward deflection in aVR is steeper than the terminal upward deflection, giving a vi/vt ratio >1. All of these criteria are consistent with aberrantly conducted SVT. The gradual rate changes during this patient's treadmill study (not shown here) were consistent with sinus tachycardia mechanism. |
 | Media file 16: This ECG shows another form of idiopathic ventricular tachycardia, seen in the absence of structural heart disease. This rhythm arises from the left ventricular septum and often responds to verapamil. Upon superficial examination, it appears to be a supraventricular tachycardia with bifascicular conduction block (RBBB/LAFB). Closer examination of lead V1 shows narrowing of the fourth QRS complex, consistent with fusion between the wide QRS complex and a conducted atrial beat, confirming VA dissociation and VT mechanism. |
 | Media file 17: This patient is a 64-year-old man with a history of prior myocardial infarction and syncope. In patients with prior myocardial infarction, the most common mechanism of wide QRS complex tachycardia is ventricular tachycardia. |
More on Ventricular Tachycardia |
| Overview: Ventricular Tachycardia |
| Differential Diagnoses & Workup: Ventricular Tachycardia |
| Treatment & Medication: Ventricular Tachycardia |
| Follow-up: Ventricular Tachycardia |
 Multimedia: Ventricular Tachycardia |
| References |
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References
Segal OR, Chow AW, Wong T, et al. A novel algorithm for determining endocardial VT exit site from 12-lead surface ECG characteristics in human, infarct-related ventricular tachycardia. J Cardiovasc Electrophysiol. Feb 2007;18(2):161-8. [Medline]. [Full Text].
Arya A, Piorkowski C, Sommer P, et al. Idiopathic outflow tract tachycardias: current perspectives. Herz. May 2007;32(3):218-25. [Medline]. [Full Text].
Noda T, Shimizu W, Taguchi A, et al. Malignant entity of idiopathic ventricular fibrillation and polymorphic ventricular tachycardia initiated by premature extrasystoles originating from the right ventricular outflow tract. J Am Coll Cardiol. Oct 4 2005;46(7):1288-94. [Medline]. [Full Text].
Kannankeril PJ, Roden DM. Drug-induced long QT and torsade de pointes: recent advances. Curr Opin Cardiol. Jan 2007;22(1):39-43. [Medline]. [Full Text].
Brugada J, Brugada R, Brugada P. Channelopathies: a new category of diseases causing sudden death. Herz. May 2007;32(3):185-91. [Medline]. [Full Text].
Wolpert C, Schimpf R, Veltmann C, et al. Clinical characteristics and treatment of short QT syndrome. Expert Rev Cardiovasc Ther. Jul 2005;3(4):611-7. [Medline]. [Full Text].
Sumitomo N, Harada K, Nagashima M, Yasuda T, Nakamura Y, Aragaki Y. Catecholaminergic polymorphic ventricular tachycardia: electrocardiographic characteristics and optimal therapeutic strategies to prevent sudden death. Heart. Jan 2003;89(1):66-70. [Medline]. [Full Text].
Chugh SS, Jui J, Gunson K, Stecker EC, John BT, Thompson B. Current burden of sudden cardiac death: multiple source surveillance versus retrospective death certificate-based review in a large U.S. community. J Am Coll Cardiol. Sep 15 2004;44(6):1268-75. [Medline]. [Full Text].
Tsatsopoulou AA, Protonotarios NI, McKenna WJ. Arrhythmogenic right ventricular dysplasia, a cell adhesion cardiomyopathy: insights into disease pathogenesis from preliminary genotype--phenotype assessment. Heart. Dec 2006;92(12):1720-3. [Medline]. [Full Text].
Rassi A Jr, Rassi A, Rassi SG. Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation. Mar 6 2007;115(9):1101-8. [Medline]. [Full Text].
Nademanee K, Veerakul G, Mower M, et al. Defibrillator Versus beta-Blockers for Unexplained Death in Thailand (DEBUT): a randomized clinical trial. Circulation. May 6 2003;107(17):2221-6. [Medline].
Yarlagadda RK, Iwai S, Stein KM, et al. Reversal of cardiomyopathy in patients with repetitive monomorphic ventricular ectopy originating from the right ventricular outflow tract. Circulation. Aug 23 2005;112(8):1092-7. [Medline]. [Full Text].
Bogun F, Crawford T, Reich S, et al. Radiofrequency ablation of frequent, idiopathic premature ventricular complexes: comparison with a control group without intervention. Heart Rhythm. Jul 2007;4(7):863-7. [Medline]. [Full Text].
Gordon T, Kannel WB. Premature mortality from coronary heart disease. The Framingham study. JAMA. Mar 8 1971;215(10):1617-25. [Medline].
Brugada P, Brugada J, Mont L, et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. May 1991;83(5):1649-59. [Medline]. [Full Text].
Vereckei A, Duray G, Szenasi G, et al. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. Jan 2008;5(1):89-98. [Medline]. [Full Text].
Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg . Canadian Implantable Defibrillator Study. Eur Heart J. Dec 2000;21(24):2071-8. [Medline].
Goldschlager N, Epstein AE, Naccarelli GV, et al. A practical guide for clinicians who treat patients with amiodarone: 2007. Heart Rhythm. Sep 2007;4(9):1250-9. [Medline].
Akhtar M, Shenasa M, Denker S, et al. Role of cardiac electrophysiologic studies in patients with unexplained recurrent syncope. Pacing Clin Electrophysiol. Mar 1983;6(2 Pt 1):192-201. [Medline].
Akhtar M, Shenasa M, Jazayeri M, et al. Wide QRS complex tachycardia. Reappraisal of a common clinical problem. Ann Intern Med. Dec 1 1988;109(11):905-12. [Medline].
Altemose GT, Buxton AE. Idiopathic ventricular tachycardia. Annu Rev Med. 1999;50:159-77. [Medline].
American Heart Association, International Liaison Committee on Resuscitation. Guidelines 2000 Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: 7C: a guide to the International ACLS algorithms. AHA in collaboration with International Liaison Committee on Resuscitation. Circulation. Aug 22 2000;102(8 Suppl):I142-57. [Medline].
AVID Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. N Engl J Med. Nov 27 1997;(22):1576-83. [Medline].
Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. Jan 20 2005;352(3):225-37. [Medline]. [Full Text].
Buxton AE, Lee KL, Fisher JD, et al. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med. Dec 16 1999;341(25):1882-90. [Medline].
Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg. Canadian Implantable Defibrillator Study. Eur Heart J. Dec 2000;21(24):2071-8. [Medline].
Fontaine G, Fontaliran F, Frank R. Arrhythmogenic right ventricular cardiomyopathies: clinical forms and main differential diagnoses. Circulation. Apr 28 1998;97(16):1532-5. [Medline].
Klein LS, Shih HT, Hackett FK, et al. Radiofrequency catheter ablation of ventricular tachycardia in patients without structural heart disease. Circulation. May 1992;85(5):1666-74. [Medline].
Mason JW. A comparison of electrophysiologic testing with Holter monitoring to predict antiarrhythmic-drug efficacy for ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators. N Engl J Med. Aug 12 1993;329(7):445-51. [Medline].
Mason JW. A comparison of seven antiarrhythmic drugs in patients with ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators. N Engl J Med. Aug 12 1993;329(7):452-8. [Medline].
Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med. Dec 26 1996;335(26):1933-40. [Medline].
Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. Mar 21 2002;346(12):877-83. [Medline]. [Full Text].
Stevenson WG, Friedman PL, Kocovic D, et al. Radiofrequency catheter ablation of ventricular tachycardia after myocardial infarction. Circulation. Jul 28 1998;98(4):308-14. [Medline].
The CASCADE Investigators. Randomized antiarrhythmic drug therapy in survivors of cardiac arrest (the CASCADE Study). Am J Cardiol. Aug 1 1993;72(3):280-7. [Medline].
Viskin S. Long QT syndromes and torsade de pointes. Lancet. Nov 6 1999;9190:1625-33. [Medline].
Further Reading
Keywords
ventricular tachycardia, VT, ischemic heart disease, ventricular fibrillation, VF, monomorphic VT, polymorphic VT, long QT syndrome, short QT syndrome, idiopathic VF, Brugada syndrome, familial adrenergic polymorphic VT, bradycardia, ischemic cardiomyopathy, dilated cardiomyopathy, hypertrophic cardiomyopathy, Chagas disease, right ventricular dysplasia, torsade de pointes, hypertrophic cardiomyopathy, right ventricular cardiomyopathy, myocarditis, coronary artery disease, hypokalemia, hyperkalemia
