This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Goldman, D. S. Articles by Moss, A. J. Search for Related Content PubMed PubMed Citation Articles by Goldman, D. S. Articles by Moss, A. J. Related Collections Pacemaker Other diagnostic testing Arrhythmias, clinical electrophysiology, drugs Epidemiology

(Circulation. 2000;102:e46.)
© 2000 American Heart Association, Inc.

Images in Cardiovascular Medicine

Malignant T-Wave Alternans

Daniel S. Goldman, MD; Wojciech Zareba, MD, PhD; Arthur J. Moss, MD

From the University of Florida, Jacksonville (D.S.G.), and the University of Rochester, Rochester, NY.

Correspondence to Daniel S. Goldman, MD, University of Florida Health Science Center, 655 W 8th St, Jacksonville, FL 32209.

A36-year-old woman was referred after her son had syncopal episodes associated with a markedly prolonged QT interval, which was treated with ß-blockers and a subsequent pacemaker. The mother had a history of "seizures" as a child that had been treated with various medications, which did not appear to affect her events. She continued to have episodes 2 to 3 times a year, and witnesses said she would "stiffen up and gasp for air." She had had no syncope for many years but had episodes of dizziness and near syncope when anxious or under emotional stress. These episodes were not associated with palpitations. Her ECG revealed a corrected QT interval of 496 (Bazzett’s formula), and an echocardiogram was remarkable for moderate mitral regurgitation without prolapse. Her QT interval did not shorten during treadmill testing. During recovery, she demonstrated biphasic inferolateral T-wave changes that were more pronounced with hyperventilation. On the basis of her long QT interval, she was placed on a ß-blocker, and in view of her near syncopal symptoms, an event recorder was placed. Most of her strips were unremarkable except for an occasional premature ventricular contraction. On one occasion when she became anxious and hyperventilated in a parking lot, she recorded the strip seen in Figure 1, showing marked T-wave alternans. On the basis of data from the International Long QT Registry,^{1 2} implantation of an implantable cardioverter-defibrillator was recommended. This was done, and 8 months later, while in a stressful situation (and on ß-blockers), the patient had the episode of polymorphic ventricular tachycardia shown in Figure 2, which was associated with syncope and required multiple shocks from her device.

View larger version (19K): [in this window] [in a new window]   Figure 1. Progressive T-wave alternans from event recorder.

View larger version (29K): [in this window] [in a new window]   Figure 2. Intracardiac electrogram from patient’s implantable defibrillator showing onset of polymorphic ventricular tachycardia followed by pretherapy tracing (confirmation) before first defibrillation.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.

References

1. Zareba W, Moss AJ, Le Cessie S, et al. T wave alternans in idiopathic long QT syndrome. J Am Coll Cardiol. 1994;23:1541–1546.[Abstract]

2. Zareba W, Moss AJ, Andrews ML, Robinson JL, and the International Long QT Registry Research Group. Visible T-wave alternans in carriers of LQT1, LQT2, LQT3 gene mutations. J Am Coll Cardiol. 2000;35(suppl A):160A. Abstract.

This article has been cited by other articles:

				T. Klingenheben, G. Gronefeld, Y.-G. Li, and S. H. Hohnloser Effect of metoprolol and d,l-sotalol on microvolt-level T-wave alternans: Results of a prospective, double-blind, randomized study J. Am. Coll. Cardiol., December 1, 2001; 38(7): 2013 - 2019. [Abstract] [Full Text] [PDF]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Goldman, D. S. Articles by Moss, A. J. Search for Related Content PubMed PubMed Citation Articles by Goldman, D. S. Articles by Moss, A. J. Related Collections Pacemaker Other diagnostic testing Arrhythmias, clinical electrophysiology, drugs Epidemiology