Bidirectional Ventricular Tachycardia

Report:

Bidirectional ventricular tachycardia

Probable digoxin toxicity

Supraventricular rhythm of uncertain origin ? atrial fibrillation

VEB

Multiform ventricular tachycardia

Comment:

Despite the adverse prognosis and her age, she was discharged home 10 days later96.

This example is not quite typical97 in that the V1 beats show RBBB-like morphology in only one of them, the penultimate beat of the tachycardia. The other one looks like LBBB, where its slow S descent betrays a ventricular ectopic origin. The last three beats probably signify the resumption of the bidirectional VT.

The digoxin level98 was only 1.7 [0.7 – 1.4], but she was febrile, septic and on salbutamol, with dilated heart and 81 years of age. The potassium was 3.6 [3.5 – 5.0] and the routine lab tests were normal. Digoxin was stopped. There was no recurrence. Her AF trace, with reasonable AV block at the ventricular rate of 77/min despite her toxic state, is shown below. Ventricular bigeminy is, of course, always suspicious of digitalis toxicity.

108a. AF with ‘controlled’ response and an episode of ventricular bigeminy. 109. A 70 year old man in biventricular failure following delayed aortic valve replacement.