BUNDLE BRANCH REENTRY VENTRICULAR TACHYCARDIA

Case presented by:

ZALMEN BLANCK, MD

A 57-year-old man underwent mechanical aortic valve replacement for severe aortic insufficiency due to a bicuspid valve. Preoperative evaluation revealed a severely dilated left ventricle (LV) (6.9 cm at end diastole and 5.8 cm at end systole), left ventricular ejection fraction (LVEF) 54% and no coronary artery disease by coronary angiography. The ECG is shown in Figure 38.1. Three days after discharge, he had 2 syncopal episodes at home. Echocardiogram showed normal prosthetic valve function and LVEF of 49%; ECG is shown in Figure 38.2. Inpatient cardiac monitoring for 36 hours revealed sinus rhythm and no significant arrhythmias. On postoperative day 3, he had developed runs of self-terminating wide-complex tachycardia at 250 bpm (Figure 38.3). He was treated with amiodarone for the same.

Question No. 1: What is the likely cause of this patient’s syncopal spells?

A.Vasovagal syncope.

B.Intermittent heart block.

C.Rapid atrial arrhythmia.

D.Monomorphic ventricular tachycardia (VT).

E.Bundle branch reentry (BBR) VT.

Question No. 2: What would be the most appropriate management?

A.Increase amiodarone and metaprolol doses.

B.Outpatient long-term cardiac monitoring.

C.Transesophageal echocardiography to assess prosthetic valve function.

D.Electrophysiologic studies.

E.Dual-chamber implantable cardioverter-defibrillator (ICD) implantation.

Figure 38.1. The 12-lead ECG before aortic valve surgery showed sinus rhythm with a PR interval of 170 ms, a QRS complex measuring 130 ms and a left bundle branch block (LBBB).

Figure 38.2. Three days after aortic valve surgery, the ECG showed a PR interval of 210 ms, widening of the QRS complex to 165 ms and leftward axis.

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