Andrés F. Miranda-Arboleda

Young Male With Incessantly Wide Complex Tachycardia: What Is the Substrate of the Arrhythmia?

A 26-year-old male with no past medical issues presented with 24-hour sudden onset palpitations, chest discomfort, and dizziness. He was hemodynamically stable and his heart rate was 189 bpm, with no other remarkable findings on physical examination. A 12-lead ECG (Figure 1) showed regular wide complex tachycardia with right bundle-branch block and extreme superior axis. Stepwise management was provided with vagal maneuvers, escalating doses of adenosine, uptitrated intravenous verapamil, and cardioversion with serial discharges ≤270 J of biphasic energy. However, all interventions were ineffective, and the tachycardia remained incessant. What is the arrhythmia, and what cardiac structure is involved in its origin? Figure 1. Twelve-lead ECG recorded in the emergency department showing a regular wide complex tachycardia with right bundle-branch block morphology and right superior axis deviation. Please turn the page to read the diagnosis. The ECG shows a regular wide complex tachycardia with right bundle-branch block morphology and right superior axis, suggesting a fascicular ventricular tachycardia (VT), poor responsiveness to intravenous verapamil, and cardioversion is not characteristic of this …

Leukogram Profile and Clinical Status in vivax and falciparum Malaria Patients from Colombia

Introduction. Hematological alterations are frequent in malaria patients; the relationship between alterations in white blood cell counts and clinical status in malaria is not well understood. In Colombia, with low endemicity and unstable transmission for malaria, with malaria vivax predominance, the hematologic profile in malaria patients is not well characterized. The aim of this study was to characterize the leukogram in malaria patients and to analyze its alterations in relation to the clinical status. Methods. 888 leukogram profiles of malaria patients from different Colombian regions were studied: 556 with P. falciparum infection (62.6%), 313 with P. vivax infection (35.2%), and 19 with mixed infection by these species (2.1%). Results. Leukocyte counts at diagnosis were within normal range in 79% of patients and 18% had leucopenia; the most frequent alteration was lymphopenia (54%) followed by monocytosis (11%); the differential granulocyte count in 298 patients revealed eosinophilia (15%) and high basophil counts (8%). Leukocytosis, eosinopenia, and neutrophilia were associated with clinical complications. The utility of changes in leukocyte counts as markers of severity should be explored in depth. A better understanding of these hematological parameters will allow their use in prompt diagnosis of malaria complications and monitoring treatment response.

Response by Miranda-Arboleda et al to Letter Regarding Article, “Young Male With Incessantly Wide Complex Tachycardia: What Is the Substrate of the Arrhythmia?”

We thank Wang and Zhao for their interest in our recently published article.1 We agree that the emergency department ECG is very suggestive of ventricular tachycardia, specifically of fascicular ventricular tachycardia (verapamil sensitive); however, the initial management with vagal maneuvers and adenosine, although usually reserved for supraventricular atrioventricular reciprocating tachycardias, can also provide diagnostic information by demonstrating atrioventricular dissociation and suggesting a ventricular …

What Is the Structural Abnormality in This Patient

A 59-year-old man presented to our hospital reporting 3 months of exertional dyspnea, ortopnea, paroxysmal nocturnal dyspnea, and lower leg edema. On physical examination, he had jugular venous distention, bibasilar rales, large tender liver, and peripheral edema. On cardiac auscultation, he had a regular heart rate with premature ventricular contractions, systolic ejection grade III/VI cardiac murmur in pulmonic area, and louder P2 than A2. Chest x-ray showed cardiac enlargement, and an ECG (Figure 1) was recorded; because of premature heartbeats on admission, a 24-hour Holter ECG was obtained (Figure 2). On the basis of ECG findings, what is the rhythm of the patient and what is the structural abnormality? Figure 1. ECG obtained during emergency department admission. Figure 2. Twenty-four–hour Holter ECG showing 1 premature ventricular contraction. Please turn the page to read the diagnosis. To interpret the ECG and determine the anatomic abnormality in this case, it is necessary to take into account the clinical and ECG findings in combination, which are remarkable for right ventricle (RV) failure as demonstrated by the findings on physical examination of jugular venous distention, large tender liver, and peripheral lower leg edema. In addition, there is a systolic murmur, fixed splitting of S2 and louder P2, thus suggesting an interatrial septal defect. The ECG shows a sinus rhythm with an extremely tall P wave in inferior and precordial leads and notable increased duration and depth of terminal-negative portion of P wave in …

Sinus node injury during adjunctive superior vena cava isolation in a patient with triggered atrial fibrillation

Introduction Atrial fibrillation is the most common sustained heart arrhythmia. Premature beats arising from foci other than pulmonary veins have been related to its pathogenesis. Methods and results A 64-year-old female underwent superior vena cava (SVC) isolation after triggers were identified originating from the SVC following pulmonary vein isolation; immediately after SVC isolation, she developed junctional rhythm with symptomatic hypotension requiring emergent management. Apical motion abnormalities were noticed in the echocardiography suggesting stress-induced cardiomyopathy which resolved 48 hours later. Although received a dual chamber pacemaker, intact sinus node function returned 2 weeks later. Conclusion Superior vena cava isolation in those with trigger mediated atrial fibrillation following pulmonary vein isolation (PVI) is performed to enhance long-term outcomes. Sinus node injury has been related previously to this procedure. We present the first case of time course of recovery of sinus node function, injured during SVC isolation.