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SVT With a Twist: Is It All What It Seems?

A 62-year-old retired police officer was referred to our institution for an episode of sustained monomorphic wide complex tachycardia requiring defibrillation at a peripheral hospital. He had a history of hypertension and hyperlipidemia and his only medication at presentation was atorvastatin. The morning of his presentation he felt fatigued and light-headed. He presented to the emergency room and his resting electrocardiogram (ECG) revealed a wide complex tachycardia (WCT) at 190 bpm with a left bundle branch block pattern. He was cardioverted with 200 J and admitted to hospital. His postcardioversion ECG revealed sinus rhythm with subtle inferolateral ST depression and T-wave inversion A transthoracic echocardiogram and coronary angiogram were unremarkable. A cardiac MRI was not tolerated by the patient due to severe claustrophobia. The patient was started on metoprolol 25 mg po twice daily and discharged with an outpatient referral for an electrophysiology assessment at our institution. At EP study, a decapolar coronary sinus catheter was placed from the left subclavian vein, and the remainder of the catheters, including a quadrapolar RV and HRA catheter, and a His catheter, were placed from the right femoral vein. The clinical tachycardia was easily inducible with atrial extra-stimuli. Both entrainment from the RV catheter as well as His refractory PVCs (Fig. 1) were introduced.