We report a 55 year-old man with sudden cardiac arrest. Electrocardiography revealed runs of
bidirectional ventricular tachycardia, and transthoracic echocardiography showed indirect
findings of pulmonary embolism. (Cardiol J 2010; 17, 2: 194-195

Aktoz, Meryem

Altun, Armagan

Barutcu, Ahmet

Tatli, Ersan

English

Via Medica Journals

CASE REPORTCardiology Journal2010, Vol. 17, No. 2, pp. 194–195Copyright © 2010 Via MedicaISSN 1897–5593194 www.cardiologyjournal.orgAddress for correspondence: Ersan Tatli, Department of Cardiology, Trakya University School of Medicine, Edirne, Turkey,tel: 902842357641/2150, fax: 902842357652, e-mail: ersantatli@yahoo.comReceived: 27.04.2009 Accepted: 14.06.2009Bidirectional tachycardia ina patient with pulmonary embolismErsan Tatli, Meryem Aktoz, Ahmet Barutcu, Armagan AltunDepartment of Cardiology, Trakya University School of Medicine, Edirne, TurkeyAbstractWe report a 55 year-old man with sudden cardiac arrest. Electrocardiography revealed runs ofbidirectional ventricular tachycardia, and transthoracic echocardiography showed indirectfindings of pulmonary embolism. (Cardiol J 2010; 17, 2: 194–195)Key words: bidirectional tachycardia, pulmonary embolismIntroductionBidirectional ventricular tachycardia (BVT) isan uncommon type of ventricular tachycardia withatypical right bundle branch block pattern in rightprecordial leads and alternating polarity of the QRScomplex in frontal plane leads [1].Bidirectional ventricular tachycardia is mostcommonly linked to digitalis toxicity, aconitepoisoning, familial hypokalemic periodic paralysis,catecholaminergic polymorphic ventricular tachycar-dia, ischemic heart disease, and myocarditis [1–4].To the best of our knowledge, this case is the firstreport of the coexistence of BVT with acute pul-monary embolism.Case reportA 55 year-old man presented with sudden car-diac arrest. Upon arrival in the emergency room,his blood pressure was 90/60 mm Hg, his heart ratewas 125/min, and his respiratory rate was 24/min.His serum electrolytes (sodium and potassium)were normal. He had no history of digitalis or oth-er herbal poison ingestion or of a similar cardiacproblem or sudden cardiac death in his family. Theelectrocardiography revealed tachycardia witha borderline narrow QRS complex of 115 ms, analternating left-and right-axis deviation in thefrontal plane leading to the bidirectional appearancein the limb leads (Fig. 1). An emergency bedsideechocardiogram showed right ventricle dilatation,mild tricuspid regurgitation and a peak tricuspidregurgitation pressure gradient of 40 mm Hg, withparadoxical motion of the interventricular septum.D-dimer level, from a blood sample taken during thearrest, was grossly elevated at 1092 µg/L (normal< 200 µg/L). Thorax computerized tomography orpulmonary angiography for the diagnosis of pulmo-nary embolism was not done owing to the hemody-namic instability of the patient.At this point, pulmonary embolism was sus-pected and emergency 20 mg boluses of recom-binant tissue type plasminogen activator were ad-ministered via femoral vein, followed by an infusionof 90 mg over one hour. Serial troponin I measure-ments were within normal range. However, thepatient died after two hours.DiscussionBidirectional ventricular tachycardia has beendescribed in a variety of clinical settings, includingdigitalis toxicity, herbal aconite poisoning, catecho-laminergic polymorphic ventricular tachycardia,coronary artery disease, and structurally normalhearts [1–4]. A negative history for intake of digi-talis and herbal poison ruled out drug toxicity as195Ersan Tatli et al., Bidirectional tachycardia in a patient with pulmonary embolismwww.cardiologyjournal.orgpossible causes of BVT. Normokalemia  and nor-mal troponin I levels removed electrolyte abnormal-ity and ischemic heart disease from the differentialdiagnosis. In the present case, BVT was most like-ly due to pulmonary embolism.Bidirectional ventricular tachycardia is nota homogeneous clinical syndrome and thereforemay have more than one mechanism. However, au-tomaticity or triggered activity is more often impli-cated than reentry [2].The correction of reversible factors (e.g. heartfailure, digoxin excess, electrolyte abnormalities)is an important part of the treatment of BVT as inour patient.As a temporary measure for patients withoutdigoxin toxicity and with sustained hemodynamical-ly compromising BVT, antiarrhythmic drugs maybe used. Lidocaine is a reasonable drug as a firstchoice [5]. Quinidine and flecainide can be used, iflidocaine is ineffective in this patient [6]. Othertreatments for tachyarrhythmias include antitachy-cardia pacing and electrical cardioversion.Bidirectional ventricular tachycardia is com-monly described as a tachycardia with alternatingQRS axis in the frontal plane on a beat-to-beat ba-sis. However, there are at least three cases in whichthe bidirectional morphology of the tachycardia wascaused by alternating right and left bundle branchblock type pattern [7].To our knowledge, this is the first report ofBVT most likely due to pulmonary embolism. Ourcase strengthens the need for a thorough search forpulmonary embolism, if there is no other obviouscause of ventricular arrhythmias.The author of this manuscript has certified thathe complies with the Principles of Ethical Publi-shing in the International Journal of Cardiology [8].AcknowledgementsThe authors do not report any conflict of inte-rest regarding this work.References1. Moorman JR, Pritchett ELC. The arrhythmias of digitalis intoxi-cation. Arch Intern Med 1985; 145: 1289–1292.2. Tai YT, Lau CP, But PPH, Fong PC, Li JPS. Bidirectional tachy-cardia induced by herbal aconite poisoning. Pacing Clin Electro-physiol, 1992; 15: 831–839.3. Li JM, Welch PJ, Zagrodzky JP, Hamdan MH. Bidirectional tachy-cardia eliminated with radiofrequency ablation. Pacing Clin Elec-trophysiol, 2002; 25: 1786–1787.4. Khan IA. Exercise-induced bidirectional ventricular tachycardiawith alternating right and left bundle branch block type patterns:A case report. Angiology, 2002; 53: 593–598.5. Castellanos A, Ferreiro J, Pefkaros K, Rozanski JJ, Moleiro F,Myerburg RJ. Effects of lignocaine on bidirectional tachycardiaand on digitalis-induced atrial tachycardia with block. Br Heart J,1982; 48: 27–32.6. Martini B, Buja GF, Canciani B, Nava A. Bidirectional tachycardia.A sustained form, not related to digitalis intoxication, in an adultwithout apparent cardiac disease. Jpn Heart J, 1988; 29: 381–387.7. Haghjoo M, Arya A, Alizadeh A, Sadr-Ameli MA. Bidirectionalventricular tachycardia and fatty infiltration of the anterior rightventricular free wall. Cardiol Rev, 2006; 14: e5–e7.8. Coats AJ. Ethical authorship and publishing. Int J Cardiol, 2009;131: 149–150.Figure 1. Bidirectional tachycardia at 125 bpm.

Bidirectional tachycardia in a patient with pulmonary embolism

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Bidirectional tachycardia in a patient with pulmonary embolism

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