WIDE COMPLEX

TACHYCARDIA

VT VS SVT

Presented by

Dr Neeraj Nirala

GUIDE

Dr Neera Samar

UNIT HEAD

Dr R.L. Meena

CASE 1

50 yr old male, labourer, smoker with H/O OF MI

5yr back admitted in ICCU with c/o of palpitation,

feeling of uneasiness for duration of 4-6 hrs.

no h/o chest pain, dyspnoea, syncope

o/e-

conscious,oriented

no pallor, cyanosis, clubbing, edema

JVP raised.

BP- 80/60 mm hg

ECG AT TIME OF ADMISSION (BEFORE DC)

ECG AT TIME OF ADMISSION

ECG -AFTER DC CARDIOVERSION (200J)

DIFFERENTIAL DIAGNOSIS

Ventricular tachycardia

Supra ventricular tachycardia with abberant

conduction due to right or left BBB

DISCUSSION –WIDE COMPLEX TACHYCARDIAS

Definition

Ecg features

Diagnostic criteria

- Brugada criteria

- Lead aVR algorithm

- Ultrasimple Brugada criterion:

RW to peak Time (RWPT)

DEFINITION

Wide QRS complex tachycardia is a rhythm with a rate of more than

100 b/m and QRS duration of more than 120 ms

VT (80%)

SVT (20%)

VT- Non-sustained VT: three or more ventricular beats with a

maximal duration of 30 seconds.

Sustained VT: a VT of more than 30 seconds duration (or less if treated by electrocardioversion within 30 seconds).

Monomorphic VT: all ventricular beats have the same configuration.

Polymorphic VT: the ventricular beats have a changing configuration. The RR interval is 180-600 ms

Biphasic VT: a ventricular tachycardia with a QRS complex that alternates from beat to beat.

SVT- a tachycardia dependent on participation of structure at or above bundle of His

LBBB morphology- QRS > 12 msec. with prominent negative deflection in V1

RBBB morphology- QRS > 12 msec. with prominent positive deflection in V1.

PHYSICAL EXAMINATION

Signs of AV dissociation favours VT

- cannon waves

- varying intensity of S1

- variation of systolic BP

- hypotension

Termination of WCT with maneuvers ~

carotid,vasalva,adenosine favours SVT

BRUGADA CRITERIA

STEP 1- RS COMPLEX IN PRECORDIAL LEADS

STEP 2- R TO NADIR OF S (BRUGADA SIGN)

STEP 3- A-V DISSOCIATION

STEP.4- QRS MORPHOLOGY

OTHER ECG FINDINGS FAVOUR VT

North - west QRS axis deviation i.e superior and rightward

minus 90 degree to 180 degree

Negative or positive concordance of QRS complex in all

precordial leads

AV dissociaton : Fusion beats, capture beats

In LBBB, QRS duration >160 ms

In RBBB,QRS duration > 140 ms

Previous ECG show MI

RABBIT EAR IN RBBB PATTERN

CONCORDANCE & NORTH WEST AXIS

POSITIVE CONCORDANCE

FUSION & CAPTURE BEATS

A fusion beat is descriptive term for the merging of an ectopic beat and a capture

beat.

When an ectopic rhythm is present, as in ventricular tachycardia, the ectopic foci

may conduct in a retrograde direction. If the ventricles are not refractory, this

leads to a conducted P wave that causes a normal QRS to follow. This is a

capture beat. However, when the ectopic focus fires at the same time that the P

wave reaches the ventricles, the QRS is a "combination" of the capture and

ectopic morphology.

So, ECG strip shows series of ectopic beats (a run of Vtach; the ectopic rhythm)

followed by capture beats (normal configuration; the sinus rhythm) and then a

gradual merging of the capture beats into the ectopic beats.

AVR ALGORITHM

If the distance traveled on the Y axis in the initial

40ms of the QRS complex is smaller than that

traveled in the terminal 40ms of the QRS complex, a

VT is much more likely

ULTRASIMPLE BRUGADA CRITERION: RW TO PEAK

TIME (RWPT)

In 2010 Joseph Brugada et al. published a new

criterion to differentiate VT from SVT in wide

complex tachycardias: the R wave peak time in

Lead II [4].

They suggest measuring the duration of onset of

the QRS to the first change in polarity (either nadir

Q or peak R) in lead II. If the RWPT is ≥ 50ms the

likelihood of a VT very high (positive likelihood ratio

34.8).

ECG DISCUSSION

Rate : 180 ventricular rate

Rhtdym : regular

Axis : normal

P wave not clearly discernable

QRS COMPLEX: Slurred wide complex of duration

200msec

QS PATTERN in V1 to V4

BRUGADA’s criteria

Step 1: RS complex inV4 lead

Step 2 : RS duration is 120msec

All these favours VT

AVR ALGORITM

Step 1: intial r wave : absent

Step 2: r wave is 50 msec

This favours VT

Ultrasimple Brugada criterion: RW to peak Time

(RWPT)

Here RWPT IS 60msec

This favors VT

OUR ECG

h/o MI

V4 RS complex

duration RS >100 ms

A-v dissociation

Avr s/o vt

RWPT > 50ms

Axis is normal

Not typical vt LBB

morphology

Qrs duration .14 s with

lbbb

Non concordance

Presence of RS complex

Favours VT •Against VT

CONCLUSION-DIAGNOSIS

VENTRICULAR TACHYCARDIA WITH LBBB

MORPHOLOGY

CAD- OLD ANT.SEPTAL MI

A 26yrs old man presented to emergency with

complaints of feeling of uneasiness , heaviness in

chest, dyspnoea with no significant past history of

any medical illness

O/E

BP 80/60

No P/CY/CL/ICT/LAP/EDEMA

CASE 2

DISCUSSION

Rate : 210 ventricular rate

Rhythm : not sinus

P wave cant be discernable

QRS COMPLEX : Wide ; duration is nearly 160 msec

Concordance: NO

Fusion beats and AV dissociation : NO

Applying Brugada algorithmStep 1: rS complex present

Step 2: rS complex duration: here 80msec

Step 3: av dissociation here absent

Step 4 : morphological criteria

RBBB pattern is present

In V1 : rSR pattern

In V6 : height of S > R so R/S > 1

All these finding favours that it is SVT with abberancy

AVR algorithm

Intial R wave in AVR : NO

Wave r = 40 msec

No notching in decending limb and no negative predominace of QRS

Vi < Vt

All these favours SVT with abberancy

Ultrasimple Brugada criterion: RW to peak Time (RWPT)

HERE RWPT is 40msec in Lead II

So it is favours SVT with abberancy

PREVOST BATELLI

DISCOVERY OF DEFIBRILLATOR

Defibrillation was invented in 1899 by Prevost and Batelli,

Two physiologists from University of Geneva, Switzerland. They discovered

that small electric shocks could induce ventricular fibrillation in dogs, and that

larger charges would reverse the condition.

THANK YOU