Coexistence of Atrial Flutter and Slow Ventricular Tachycardia

Figures

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  Visual Summary. Clinical Timeline of Successful Radiofrequency Ablation for Atrial Flutter with Concomitant Ventricular Tachycardia ECG = electrocardiogram; TTE = transthoracic echocardiography.

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  Figure 1. ECG on Initial Presentation The ECG shows limb leads I, II, and III predominantly positive (blue rectangle), an R-wave peak time in lead II >50 ms (orange rectangle), amplitude of the first 40 ms < amplitude of the last 40 ms of QRS (yellow rectangle), a QS complex in lead V1 (pink rectangle), RS interval in a precordial lead >100 ms with R to nadir of S >60 ms in lead V2 (LBBB configuration; purple rectangle), and an R/S ratio in V6 >1 (green rectangle), with a Jastrzębski VT score of 3 and Pachón score of 1, indicating VT and an equivocal result, respectively. ECG = electrocardiogram; LBBB = left bundle branch block; VT = ventricular tachycardia.

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  Figure 2. Dynamic ECG From 7 Years Ago ECG from 7 years prior demonstrates VT with clear AV dissociation (the red star identifies the dissociation between the atria and ventricles). Notably, it also captures sinus beats with markedly narrowed QRS complexes in the simulated leads. ECG = electrocardiogram; AV = atrioventricular; VT = ventricular tachycardia.

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  Figure 3. Surface ECG and Intracardiac Electrogram After the Termination of Atrial Flutter ECG = electrocardiogram.

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  Figure 4. S1S1 Coronary Sinus Stimulation Performed During the Procedure The S1S1 coronary sinus stimulation resulted in a noticeable narrowing of the QRS complex, suggesting that ventricular conduction may have partially recovered through the atrioventricular node or the His-Purkinje system.

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  Figure 5. High-Frequency Purkinje Potential on PentaRay Activation Map During VT, the PentaRay activation map localized the origin to the right fascicular bundle, evidenced by a high-frequency Purkinje potential preceding the QRS by 18 ms at the right midseptum. The red arrows denote ensuing antegrade Purkinje potentials. VT = ventricular tachycardia.

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  Figure 6. Sinus Rhythm Featuring a Narrow QRS Complex Observed During VT Ablation VT = ventricular tachycardia.

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  Figure 7. Postoperative ECG The observed right bundle branch block is likely iatrogenic, resulting from ablation near the conduction system at the site of earliest VT activation. ECG = electrocardiogram; VT = ventricular tachycardia.