© 2005 European Society of Cardiology
Recovery of systolic and diastolic function after ablation of incessant supraventricular tachycardia
Myocardiopathies Unit, Department of Cardiology, Heart Institure (InCor), University of Sao Paulo Medical School São Paolo, 05403900, Brazil
* Corresponding author. Tel./fax: +5511 50569812. E-mail address: verasalemi{at}uol.com.br
 |
Abstract |
|---|
 Top Abstract 1. Case Report2. DiscussionAcknowledgmentReferences |
|---|
We report a case of a 26-year-old woman who presented to our hospital with arrhythmia and heart failure. She had an incessant supraventricular tachycardia, which was not reversible with electrical cardioversion. Echocardiogram showed a severe LV systolic and diastolic dysfunction. After radiofrequency catheter ablation, LV function returned to normal. This article is intended to show a case with tachycardiomyopathy, which is considered the most frequently unrecognized curable cause of heart failure, and to demonstrate that early treatment allows the recovery to a normal LV systolic and diastolic function, preventing irreversible structural cardiac damage. It is very likely that some patients with idiopathic dilated cardiomyopathy and chronic atrial fibrillation or other chronic arrhythmia actually have a curable tachycardiomyopathy.
Key Words: Tachycardiomyopathy • Systolic function • Diastolic function • Arrhythmia
Received August 17, 2004; Revised December 9, 2004; Accepted December 9, 2004
|
1. Case Report |
|---|
|
TopAbstract1. Case Report2. DiscussionAcknowledgmentReferences |
|---|
A 26-year-old mulatto female patient was admitted to the Heart Institute (InCor) with dilated cardiomyopathy, which had been diagnosed 14 months before admission. During that period, she was receiving lisinopril 10 mg/day and digoxin 0.25 mg/day. Two weeks prior to admission, her condition had become worse. At admission, she was in New York Heart Association functional class II with atypical chest pain, palpitations and dyspnoea of effort.
On examination she presented good general condition, blood pressure 100x60 mmHg and heart rate 126 bpm. The cardiac impulse was diffuse and displaced inferior and laterally. The cardiac rhythm was regular, with S3 gallop, increased P2 and mild holosystolic murmur in the mitral and tricuspid area. The rest of her physical exam was normal. Her thyroid hormones and ferritin were within the normal range, and Chagas' disease serology was negative. The electrocardiographic (ECG) characteristics of the tachycardia did not allow differentiation between atrial, sinoatrial or AV type Coumel (Fig. 1). A 24-h Holter monitoring showed sinus rhythm alternated with incessant supraventricular tachycardia. The mean heart rate was 119 bpm (44–166 bpm), and the incessant supraventricular tachycardia was present for more than two thirds of the 24-h period.
|
Standard transthoracic echocardiogram showed a dilated and severe globally hypokinetic left ventricle (LV, Fig. 2), left atrium of 47 mm, mild mitral and tricuspid regurgitations, and a restrictive left ventricular filling pattern. Electrical cardioversion was performed without success. The patient underwent electrophysiological testing, and was submitted to successful transcatheter radiofrequency ablation of accessory pathway located in the right posterio-septal zone. The patient has remained well and in sinus rhythm for the last 88 months following resolution of the tachycardia. The echocardiogram performed 6 months after the procedure showed an improvement in LV ejection fraction (Fig. 2) and, when repeated 88 months later, showed a totally normal systolic and diastolic function. Normal diastolic function was confirmed by pulsed-wave tissue Doppler imaging in septal, lateral, inferior and anterior mitral annuli (Fig. 3).
|
|
|
2. Discussion |
|---|
|
TopAbstract1. Case Report2. DiscussionAcknowledgmentReferences |
|---|
The relation between chronic tachycardia and reversible ventricular dysfunction was first described in 1949 by Phillips and Levine in patients with atrial fibrillation and heart failure. However, the dilemma "what comes first" still remains, is the ventricular dysfunction a cause or a consequence of the arrhythmia? Tachycardiomyopathy is defined as reversible myocardial dysfunction secondary to chronic ventricular or supraventricular tachycardia [1]. Reversal of the arrhythmia results in improvements in symptoms, exercise capacity, and partial or total recovery of the ventricular function, which occurs over a variable period of time. Tachycardiomyopathy may happen at any age, in a normal heart, or in a heart with congenital or acquired disease. The interaction between these variables determines the time necessary for the development of the myocardial dysfunction, its severity and its clinical presentation.
The relationship between the grade of LV dysfunction/dilation and the mean heart rate during the tachycardia is controversial [2]. In 1936 Weiss and McGuire reported 2 patients with atrial tachycardia and concluded that heart rates below 150 bpm were not dangerous if present in a normal heart [3]. Fishberger et al. [4] also found an increased heart rate in patients with worse LV function than in patients without LV dysfunction. However, another study did not show the same relationship [5]; this could be explained by other aspects of the arrhythmia that could be important to the development of LV dysfunction, such as the duration of arrhythmia, an irregular ventricular rate [6], abnormal atrio-ventricular sequencing [2] and incessant/sporadic patterns [7]. In our patient, the mean heart rate was 119 bpm, suggesting that an incessant tachycardia with heart rate below 150 bpm may provoke left ventricular dysfunction.
This patient presented an uncommon tachycardia, as described by Coumel in 1967, in which ECG hallmarks are a long RP interval that exceeds the PR interval, narrow QRS complex, inverted P waves in inferior leads and V3–V6 [8]. This tachycardia is also refractory to antiarrhythmic therapy and has an incessant manifestation. In addition, a slow and decremental right posterior septal conduction accessory pathway appears to be responsible for this type of tachycardia, with anterograde AV nodal conduction and retrograde conduction over this pathway.
In this patient, although this diagnosis had been suspected before ablation, it was not possible to confirm the presence of tachycardiomyopathy until after the LV dysfunction was shown to be reversible. Here the cardiomyopathy induced by tachycardia showed a previous negative history of cardiomyopathy, the presence of an incessant tachycardia, and, what is even more important, the reversible nature of LV systolic and diastolic dysfunction, which was demonstrated after the reversal of the arrhythmia [9].
A previous animal study has shown that there is improvement in systolic function associated with persistent diastolic dysfunction after the termination of supraventricular tachycardia [10]. In our patient, however, although the diastolic function was not analyzed by tissue Doppler imaging in the first echocardiogram, the follow-up exam showed a complete recovery to normal LV diastolic function, and a normal LV end-diastolic pressure assessed by E/E' of 3.3. This indicates that more studies are needed to better evaluate the improvement in diastolic function with the recovery of the myocardial function in patients with tachycardiomyopathy.
The "take-home-message" is to make a correct and early diagnosis of tachycardiomyopathy, which should be suspected in any patient with heart failure and chronic arrhythmia. The physician should begin treatment as soon as possible to allow complete resolution to normal LV function, and preventing irreversible structural cardiac damage.
|
Acknowledgment |
|---|
|
TopAbstract1. Case Report2. DiscussionAcknowledgmentReferences |
|---|
We are indebted to Dr. Marcelo Park for the suggestions in this case report.
|
References |
|---|
|
TopAbstract1. Case Report2. DiscussionAcknowledgmentReferences |
|---|
- Walker N.L., Cobbe S.M., Birnie D.H. Tachycardiomyopathy: a diagnosis not to be missed. Heart (2004) 90:e7–e9.
[Abstract/Free Full Text] - Fenelon G., Wijns W., Andries E., Brugada P. Tachycardiomyopathy: mechanisms and clinical implications. Pacing Clin. Electrophysiol. (1996) 19(1):95–106.[CrossRef][Medline]
- Weiss H.B., McGuire J. Ectopic tachycardia, auricular in origin, of unusual duration. Am. Heart J. (1936) 12:585–591.[CrossRef][Web of Science]
- Fishberger S.B., Colan S.D., Saul J.P., Mayer J.E. Jr., Walsh E.P. Myocardial mechanics before and after ablation of chronic tachycardia. Pacing Clin. Electrophysiol. (1996) 19(1):42–49.[CrossRef][Medline]
- Packer D.L., Bardy G.H., Worley S.J., Smith M.S., Cobb F.R., Coleman R.E., et al. Tachycardia-induced cardiomyopathy: a reversible form of left ventricular dysfunction. Am. J. Cardiol. (1986) 57(8):563–570.[CrossRef][Web of Science][Medline]
- Brugada P., Andries E. "Tachycardiomyopathy". The most frequently unrecognized cause of heart failure? Acta Cardiol. (1993) 48(2):165–169.[Web of Science][Medline]
- Kim Y.H., Goldberger J., Kadish A. Treatment of ventricular tachycardia-induced cardiomyopathy by transcatheter radiofrequency ablation. Heart (1996) 76(6):550–552.
[Abstract/Free Full Text] - Aguinaga L., Primo J., Anguera I., Mont L., Valentino M., Brugada P., et al. Long-term follow-up in patients with the permanent form of junctional reciprocating tachycardia treated with radiofrequency ablation. Pacing Clin. Electrophysiol. (1998) 21:2073–2078.[CrossRef][Medline]
- Cha Y.M., Redfield M.M., Shen W.K., Gersh B.J. Atrial fibrillation and ventricular dysfunction: a vicious electromechanical cycle. Circulation (2004) 109(23):2839–2843.
[Free Full Text] - Tomita M., Spinale F.G., Crawford F.A., Zile M.R. Changes in left ventricular volume, mass, and function during the development and regression of supraventricular tachycardia-induced cardiomyopathy. Disparity between recovery of systolic versus diastolic function. Circulation (1991) 83(2):635–644.
[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||