Unrecognized ventricular tachycardia in a patient with mitral annulus disjunction and syncope

Figures

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  Figure 1. A: Twelve-lead electrocardiogram taken during the initial hospital admission. Frequent polymorphic premature ventricular contractions in a bigeminal pattern were localized to the posteromedial mitral annulus. B: Parasternal long-axis transthoracic echocardiogram during diastole. C: Parasternal long-axis transthoracic echocardiogram during systole showing mitral annulus disjunction (MAD) of the posterior wall measuring 14 mm. D: Cardiac magnetic resonance imaging during diastole. E: Cardiac magnetic resonance imaging during systole showing MAD of the posterior wall measuring 13.7 mm.

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  Figure 2. CareLink (Medtronic, Minneapolis, MN) event report of the syncopal episode. A: Heart-rate plot diagram with dashed box that annotates the time in which the electrogram (EGM) below corresponds. Vertical arrow corresponds to trigger activation with a retrospective 4-minute timer. Horizontal arrow corresponds to the time in which the patient had fallen to the ground with sternal rubbing and resultant noise, which was not consistent with sinus tachycardia. B: EGM consisting of the final 30 seconds of the event in which the patient was in a consistent tachycardic rhythm with positive polarity, which was interpreted as sinus tachycardia, but in actuality was unstable ventricular tachycardia.

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  Figure 3. Insertable cardiac monitor electrogram of the syncopal episode proceeding from top to bottom panels in real time. A: Sinus tachycardia with negative polarity followed by abrupt shift to ventricular tachycardia (VT) with positive polarity that was initiated by a premature ventricular contraction (black rectangle). B: Continued VT with noise entering midway through the strip. C: Underlying VT with simultaneous noise detection. The black circle denotes device rejection of the ventricular fibrillation rhythm owing to noise. D: Continued underlying VT with simultaneous noise. E: Continued VT with reduced levels of noise.