|INTERESTING CASE REPORT
|Year : 2018 | Volume
| Issue : 3 | Page : 174-178
Tachycardia-induced cardiomyopathy in a teenage boy
Rajesh Krishnachandra Shah
Department of Medicine, MGM Medical College, Aurangabad, Maharashtra, India
|Date of Web Publication||10-Dec-2018|
Dr. Rajesh Krishnachandra Shah
Shrikrishna Hospital' 223, Samarthnagar, Aurangabad, 431 - 001, Bihar
Source of Support: None, Conflict of Interest: None
Tachycardiomyopathy or tachycardia-induced cardiomyopathy (TIC) is a relatively rare but completely or partially treatable condition, where there is an impairment of left ventricular (LV) function secondary to chronic, continuous, or intermittent tachycardia, which presents as heart failure. It has been shown that the rate control by means such as cardioversion, negative chronotropic agents, and surgical- or catheter-based atrioventricular nodal ablation, depending on the etiology, resulted in significant improvement of systolic function. The diagnosis of TIC is entertained following the observation of improvement in LV systolic function, after necessary therapy to control the arrhythmia or heart rate. It is necessary that the clinicians should have a high index of suspicion while dealing with LV systolic dysfunction or dilated cardiomyopathy and should control the arrhythmia stringently. This case report describes a 14-year-old boy presenting with breathlessness of 18–24-month duration who had features of dilated cardiomyopathy on echocardiography. Impaired LV systolic function was due to fascicular ventricular tachycardia and he recovered completely after catheter-based ablation within a period of 5–6 months.
Keywords: Ablation therapy, cardiomegaly, cardiomyopathy, fascicular ventricular tachycardia, tachycardia-induced cardiomyopathy, tachycardiomyopathy
|How to cite this article:|
Shah RK. Tachycardia-induced cardiomyopathy in a teenage boy. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:174-8
| Introduction|| |
Tachycardia-induced cardiomyopathy (TIC) is a relatively rare condition, requiring high index of suspicion to treat the cause, as it is a completely or sometimes a partially treatable condition.
| Clinical Presentation|| |
A 14-year-old boy presented on May 5, 2017, with breathlessness Grade II on and off fatigue and uneasiness since 1½–2 years.
On presentation, his pulse was 150/min and regular, with a systolic blood pressure of 80 mmHg. His heart sounds were normal and there were no clinical signs of heart failure. There was no history of any significant problem such as rheumatic heart disease. He was not involved in any active sports due to breathlessness.
His electrocardiogram (ECG) at presentation showed a heart rate of 151/min, with right bundle branch block (RBBB) and left anterior hemiblock with a narrow QRS complex, suggestive of fascicular ventricular tachycardia (FVT) [Figure 1].
Echocardiography done immediately showed dilated chambers of the heart with the left ventricular (LV) internal diameter measuring 54 mm. The right ventricular (RV) basal diameter was 40 mm with poor LV and RV systolic function and an LV ejection fraction (LVEF) of 20%. On the first echocardiography, global longitudinal strain (GLS) was not performed [Videos 1-3 and [Figure 2]. The dilemma here was whether it was dilated cardiomyopathy causing arrhythmia or repeated arrhythmia causing dilated cardiomyopathy.
As he was hemodynamically stable, he was given tablet Metoprolol 25 mg and tablet torsemide 5 mg. The repeat ECG done in the intensive care unit (ICU) showed sinus rhythm with a heart rate of 70/min, LV hypertrophy, and global “T” wave inversion [Figure 3]. Repeat echocardiogram in the ICU, on May 7, 2017, showed the same changes, with LVEF of 20% and RV dysfunction.
He was advised electrophysiology (EP) studies, which he underwent after 1 month. The echocardiogram before EP studies, i.e., on June 7, 2017, which was done at a different center showed a report mentioning LVEF of 45%, thus showing improvement within 1 month of control of tachycardia. The EP study confirmed the presence of FVT, and he underwent radiofrequency ablation for it.
Echocardiogram done after 2½ months, i.e., on June 25, 2017, showed mild improvement in LV Function, with LFEF of 46% and GLS of 11% [Videos 4-6 and [Figure 4] and [Figure 5].
The LVEF by Simpson's method was done which showed EF of 46% [Figure 6] and [Figure 7]. The fractional area change (FAC) of the RV was 7.3% [Figure 8] and [Figure 9].
|Figure 8: Right ventricular fractional area change, end diastolic area on July 25, 2017|
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|Figure 9: Right ventricular fractional area change, end systolic area on July 25, 2017|
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Echocardiogram done 5½ months later, i.e., on October 11, 2017, showed near normal LVEF of 53.3% and GLS of 14.5% [Videos 7-9 and [Figure 10] and [Figure 11]]. The summary of the changes seen is shown in [Table 1].
The LVEF by Simpson's method showed LVEF of 53.3% [Figure 12] and [Figure 13]. The RV function also improved with a FAC of 33.8 [Figure 14] and [Figure 15].
|Figure 14: Right ventricular fractional area change, end systolic area on October 11, 2017|
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|Figure 15: Right ventricular fractional area change, end diastolic area on October 11, 2017|
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| Discussion|| |
Whipple et al. first described experimental TIC in 1962. The condition was first coined by Gallagher.
The term TIC or tachycardiomyopathy refers to impairment in LV function secondary to chronic tachycardia, which is partially or completely reversible once the tachyarrhythmia is controlled. TIC can occur both in experimental animals and in patients with tachyarrhythmia. It has been shown that the rate control by means of cardioversion, negative chronotropic agents, and surgical- or catheter-based atrioventricular (AV) node ablation, depending on the etiology, resulted in significant improvement of systolic function.
TIC can occur with any type of chronic or frequently recurring atrial, AV, and VT. TIC can occur at any age. It has been reported in infants, children, adolescents, and adults.,
FVT is also known as idiopathic VT, as it occurs in the absence of structural heart disease; it is the most common type of idiopathic VT arising from the LV and is seen in 10% of the VT. It is a reentrant type of tachycardia. It is nonresponsive to adenosine, vagal maneuvers, and lidocaine but responds best to verapamil. It usually occurs in young healthy patients between the ages of 15–40 years. The distinguishing features of FVT are:
- It is a monomorphic VT and has AV dissociation, fusion, and captured beats, which help differentiate it from supra-VT with RBBB
- The QRS duration is between 100 and 140 ms; thus, it is a narrow complex tachycardia as against the other types of VT
- It has an RBBB pattern.
The exact incidence of TIC is not known. In patients with atrial fibrillation, approximately 25%–75% of those with LV dysfunction had some degree of TIC.,,,,
Tachycardiomyopathy can be seen with very frequent premature ventricular contractions, VT of outflow tract of the RV, and fascicular tachycardia.,
Underlying histologic changes are characterized by cardiomyocyte lengthening and hyperplasia, extracellular matrix changes, myocardial fibrosis, myofibril misalignment, loss of sarcomere register, and apoptosis.,
The mechanisms of tachycardiomyopathy are not fully defined but include subclinical ischemia, abnormalities in energy metabolism, redox stress, and calcium overload. In addition to poor LV systolic function, patients with TIC have a smaller LV end-diastolic dimension compared to patients with idiopathic dilated cardiomyopathy.,
This profound cardiac dilatation is typically accompanied by RV and LV wall thinning, markedly elevated ventricular filling pressures, and decreased contractile state with severe impairment of systolic function.,,,
Certain important facts about tachycardia-induced cardiomyopathy
- Tachycardiomyopathy usually develops at heart rates above 100/min; faster the rate, higher the chances of development of TIC
- It is more common with ventricular rather than atrial arrhythmias, and it develops faster with ventricular arrhythmias
- Incessant ectopic atrial tachycardia is a less common cause of tachycardiomyopathy. It accounts for 5% of cases of tachycardiomyopathy in adults and 14% in children
- It is more common and faster with continuous tachycardia than intermittent tachycardia
- The time of onset cannot be predicted
- The maximum recovery is usually within the 1st month, but recovery can occur up to 1 year
- The presence of mitral regurgitation (MR) begets MR, facilitating development of TIC
- Recurrence of arrhythmia induces LV systolic dysfunction faster.
| Conclusion|| |
TIC is a relatively rare condition, requiring a high index of suspicion to treat the cause, as it is a completely or sometimes a partially treatable condition.
The diagnosis of TIC is not always simple, but the treating physician should have a high index of suspicion and should start therapy if the patient suffers from congestive heart failure with tachyarrhythmias. This is because LV dysfunction may recover after adequate treatment and it is the only way to make a definite diagnosis of tachycardiomyopathy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]