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Bidirectional Ventricular Tachycardia Caused by Digitalis Toxicity

2006; Lippincott Williams & Wilkins; Volume: 113; Issue: 7 Linguagem: Inglês

10.1161/circulationaha.105.557561

1524-4539

Joseph L. Kummer, Rajiv Nair, Subramaniam Krishnan,

Cardiac Arrhythmias and Treatments

HomeCirculationVol. 113, No. 7Bidirectional Ventricular Tachycardia Caused by Digitalis Toxicity Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBBidirectional Ventricular Tachycardia Caused by Digitalis Toxicity Joseph L. Kummer, MD, Rajiv Nair, MD and Subramaniam C. Krishnan, MD Joseph L. KummerJoseph L. Kummer From Henry Ford Heart and Vascular Institute, Detroit, Mich. , Rajiv NairRajiv Nair From Henry Ford Heart and Vascular Institute, Detroit, Mich. and Subramaniam C. KrishnanSubramaniam C. Krishnan From Henry Ford Heart and Vascular Institute, Detroit, Mich. Originally published21 Feb 2006https://doi.org/10.1161/CIRCULATIONAHA.105.557561Circulation. 2006;113:e156–e157A 70-year-old black man with a history of hypertension and idiopathic cardiomyopathy was admitted to our hospital after presenting to the emergency department with cellulitis, sepsis, respiratory failure, and acute renal failure. The initial ECG revealed atrial fibrillation with a rapid ventricular response and a left bundle-branch block (LBBB). The ventricular response was accelerated by vasopressor agents administered for septic shock. He received intravenous esmolol and a total of 1 mg of digoxin intravenously during the next 36 hours to control the ventricular rate. On hospital day 2, he also received an enteral dose of 0.125 mg of digoxin. This occurred in the setting of acute tubular necrosis requiring the initiation of hemodialysis. On hospital day 3, an ECG was performed that demonstrated QRS complexes with an alternating shift in axis (Figure 1). A diagnosis ofbidirectional ventricular tachycardia was made. Although the QRS duration during the arrhythmia was prolonged, it remained narrower than the patient's intrinsic QRS with the LBBB. The arrhythmia spontaneously abated. Intra-arterial hemodynamic monitoring during the arrhythmia displayed pulsus alternans (Figure 2). Download figureDownload PowerPointFigure 1. Bidirectional ventricular tachycardia. Note the alternating QRS axes and right bundle-branch block type morphology. This occurred in the setting of a supratherapeutic serum level of digoxin as a consequence of acute renal failure.Download figureDownload PowerPointFigure 2. Pulsus alternans. Lower tracing is an intra-arterial pressure recording during bidirectional ventricular tachycardia; 4 mm on the vertical axis of the pressure tracing represents 80 mm Hg of systemic arterial pressure. Note that the systolic pressure displays an alternating beat-to-beat variability from &120 mm Hg to 140 mm Hg.The patient's serum digoxin level was 3.9 ng/mL, which is nearly twice the upper limit of the therapeutic range. Serum potassium and magnesium were within normal limits. The digoxin was discontinued. The patient subsequently had brief recurrences of the ventricular tachycardia, but, by hospital day 6, his rhythm had stabilized. He remained in atrial fibrillation with LBBB, and the ventricular rate was controlled with oral metoprolol.FootnotesCorrespondence to Subramaniam Krishnan, MD, Electrophysiology and Pacing Laboratory, Henry Ford Heart and Vascular Institute, 2799 W Grand Blvd, Detroit, MI 48202. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Vemireddy L, Aqeel A, Ying G, Majlesi D and Woo V A Rare Case of RYR2 Mutation Causing Sudden Cardiac Arrest Due to Catecholaminergic Polymorphic Ventricular Tachycardia, Cureus, 10.7759/cureus.13417 Serge Barold S (2018) Alternans during fascicular ventricular tachycardia due to digitalis toxicity, Journal of Electrocardiology, 10.1016/j.jelectrocard.2018.01.011, 51:3, (450-451), Online publication date: 1-May-2018. (2016) Cardiac glycosides Meyler's Side Effects of Drugs, 10.1016/B978-0-444-53717-1.00456-X, (117-157), . Barbieri L, Verdoia M, Schaffer A, Suryapranata H and De Luca G (2016) Risk and Benefits of Triple Therapy in Patients Undergoing Coronary Stent Implantation Requiring Oral Anticoagulation: A Meta-Analysis of 16 Studies, Cardiovascular Drugs and Therapy, 10.1007/s10557-016-6692-z, 30:6, (611-622), Online publication date: 1-Dec-2016. Senthilkumaran S, Meenakshisundaram R and Thirumalaikolundusubramanian P (2015) Plant Toxins and the Heart Heart and Toxins, 10.1016/B978-0-12-416595-3.00005-0, (151-174), . Weiss J, Garfinkel A, Karagueuzian H, Nguyen T, Olcese R, Chen P and Qu Z (2015) Perspective: A dynamics-based classification of ventricular arrhythmias, Journal of Molecular and Cellular Cardiology, 10.1016/j.yjmcc.2015.02.017, 82, (136-152), Online publication date: 1-May-2015. Kolli K, Effat M, Peelukhana S, Succop P, Back L, Leesar M, Helmy T, Imran A and Banerjee R (2014) Hyperemia-Free Delineation of Epicardial and Microvascular Impairments Using a Basal Index, Annals of Biomedical Engineering, 10.1007/s10439-014-1020-x, 42:8, (1681-1690), Online publication date: 1-Aug-2014. Bader E, Argulian E, Aziz E, Herzog E and Greenberg H (2014) EKG in Pericardial Disease Management of Pericardial Disease, 10.1007/978-3-319-06124-5_4, (37-48), . Baher A, Uy M, Xie F, Garfinkel A, Qu Z and Weiss J (2011) Bidirectional ventricular tachycardia: Ping pong in the His–Purkinje system, Heart Rhythm, 10.1016/j.hrthm.2010.11.038, 8:4, (599-605), Online publication date: 1-Apr-2011. Bauer T and Zeymer U (2010) Impact of age on outcomes of percutaneous coronary intervention in acute coronary syndromes patients, Interventional Cardiology, 10.2217/ica.10.27, 2:3, (319-325), Online publication date: 1-Jun-2010. Tristani-Firouzi M and Etheridge S (2010) Kir 2.1 channelopathies: the Andersen–Tawil syndrome, Pflügers Archiv - European Journal of Physiology, 10.1007/s00424-010-0820-6, 460:2, (289-294), Online publication date: 1-Jul-2010. Donnan G and Davis S (2009) Combined Aspirin Plus Warfarin, Stroke, 40:5, (1946-1946), Online publication date: 1-May-2009. Aronson J (2009) Positive inotropic drugs and drugs used in dysrhythmias , 10.1016/S0378-6080(09)03117-1, (321-338), . Gilard M, Blanchard D, Helft G, Carrier D, Eltchaninoff H, Belle L, Finet G, Le Breton H and Boschat J (2009) Antiplatelet Therapy in Patients With Anticoagulants Undergoing Percutaneous Coronary Stenting (from STENTIng and oral antiCOagulants [STENTICO]), The American Journal of Cardiology, 10.1016/j.amjcard.2009.03.053, 104:3, (338-342), Online publication date: 1-Aug-2009. Michelson A (2008) P2Y12 Antagonism, Arteriosclerosis, Thrombosis, and Vascular Biology, 28:3, (s33-s38), Online publication date: 1-Mar-2008.Gibbons R (2008) Noninvasive Diagnosis and Prognosis Assessment in Chronic Coronary Artery Disease, Circulation: Cardiovascular Imaging, 1:3, (257-269), Online publication date: 1-Nov-2008.Bass T and Capranzano P (2008) Managing Patients With Intermediate In-Stent Restenotic Lesions, Circulation: Cardiovascular Interventions, 1:2, (90-92), Online publication date: 1-Oct-2008.Weintraub W, Boden W, Zhang Z, Kolm P, Zhang Z, Spertus J, Hartigan P, Veledar E, Jurkovitz C, Bowen J, Maron D, O'Rourke R, Dada M, Teo K, Goeree R and Barnett P (2008) Cost-Effectiveness of Percutaneous Coronary Intervention in Optimally Treated Stable Coronary Patients, Circulation: Cardiovascular Quality and Outcomes, 1:1, (12-20), Online publication date: 1-Sep-2008.Rodés-Cabau J, DeBlois J, Bertrand O, Mohammadi S, Courtis J, Larose E, Dagenais F, Déry J, Mathieu P, Rousseau M, Barbeau G, Baillot R, Gleeton O, Perron J, Nguyen C, Roy L, Doyle D, De Larochellière R, Bogaty P and Voisine P (2008) Nonrandomized Comparison of Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention for the Treatment of Unprotected Left Main Coronary Artery Disease in Octogenarians, Circulation, 118:23, (2374-2381), Online publication date: 2-Dec-2008.Shemin R (2008) Coronary Artery Bypass Grafting Versus Stenting for Unprotected Left Main Coronary Artery Disease, Circulation, 118:23, (2326-2329), Online publication date: 2-Dec-2008. Bonnemeier H and Barantke M (2008) It Is Not Always Digitalis: Bidirectional Ventricular Tachycardia in Left Ventricular Hypertrophy, Annals of Noninvasive Electrocardiology, 10.1111/j.1542-474X.2008.00218.x, 13:2, (208-210), Online publication date: 1-Apr-2008. Goddard C, Ghais N, Zhang Y, Williams A, Colledge W, Grace A and Huang C (2008) Physiological consequences of the P2328S mutation in the ryanodine receptor ( RyR2 ) gene in genetically modified murine hearts , Acta Physiologica, 10.1111/j.1748-1716.2008.01865.x, 194:2, (123-140), Online publication date: 1-Oct-2008. BONELLO L, PAGANELLI F, ARPIN-BORNET M, AUQUIER P, SAMPOL J, DIGNAT-GEORGE F, BARRAGAN P and CAMOIN-JAU L (2007) Vasodilator-stimulated phosphoprotein phosphorylation analysis prior to percutaneous coronary intervention for exclusion of postprocedural major adverse cardiovascular events, Journal of Thrombosis and Haemostasis, 10.1111/j.1538-7836.2007.02609.x, 5:8, (1630-1636), Online publication date: 1-Aug-2007. Almarzuqi A, Kimber S, Quadros K and Senaratne J (2022) Bidirectional Ventricular Tachycardia: Challenges and Solutions, Vascular Health and Risk Management, 10.2147/VHRM.S274857, Volume 18, (397-406) February 21, 2006Vol 113, Issue 7 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.105.557561PMID: 16490826 Originally publishedFebruary 21, 2006 PDF download Advertisement SubjectsArrhythmias