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to the bedside…

the case.

a 34 year old female presents to ED with palpitations and chest pain.

You are handed her ECG prior to reviewing or speaking to the patient….

TGV-RVH + AFlutter

[DDET Describe & interpret her ECG…]

  • Rate.
    • 134 bpm
  • Rhythm.
    • Regular.
    • No obvious P’s.
  • Axis.
    • Markedly rightward [ +156* ]
  • Intervals.
    • PR – n/a
    • QRS – 90msec
    • QTc ~ 420msec
  • Additional.
    • RBBB pattern (< 120msec therefore incomplete)
    • Right ventricular hypertrophy w/ RV strain pattern
      • very large R-wave (V1) [>>7mm] + R/S >>1
      • deep S-wave [V6] + R/S <1.
      • ST depression + TWI (V1-3)
    • ?Flutter wave V2.

Interpretation.

  • Young female w/ chest pain.
  • Narrow complex tachycardia w/out clear P-waves
    • is this SVT or Atrial flutter ??
  • Incomplete RBBB w/ right ventricular hypertrophy & strain pattern.
  • Differential Dx:
    • ?Pulmonary embolism with right-heart strain
    • ?chronic lung disease w/ cor pulmonale or pulmonary hypertension
    • ?underlying congenital heart disease

[/DDET]

[DDET You head to the bedside…]

Your patient looks very well.

  • Alert & speaking full sentences.
  • Observations:
    • SaO2 100% on room air.
    • P 134. BP 126/-. RR 20.
    • Afebrile.
  • Obvious old, well-healed midline-sternotomy scar.
  • Clear chest.

“It’s ok Doc, I’ve had this before” she tells you.

Her background:

  • Transposition of Great Vessels.
  • Mustard procedure (see below).
  • Recurrent atrial flutter.
  • Previous electrophysiology studies  [multiple re-entry circuits identified and ablated].

Mustard (transposition)

[/DDET]

[DDET The diagnosis…]

Atrial flutter with right ventricular hypertrophy secondary to congenital heart disease.

[/DDET]

[DDET What happens next ??]

  • We discuss the pro’s & con’s of  electrical vs chemical cardioversion.
  • Electrical cardioversion is chosen.
    • Ketofol (30/30mg)
    • 50J synchronised shock…

TGV-RVH + sinus

  • She is discharged a few hours later !!

[/DDET]

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