Heart 1999;81:323–324 323

CASE REPORT Heart: first published as 10.1136/hrt.81.3.323 on 1 March 1999. Downloaded from

ECG diagnosis of native heart ventricular tachycardia in a heterotopic heart transplant recipient

M Vanderheyden, J de Sutter, M Goethals

Abstract respiratory distress, and a rapid irregular heart A case is reported of haemodynamic rate of approximately 150 beats/min. collapse in a 51 year old male heterotopic The 12 lead ECG (fig 1) showed a broad heart transplant recipient caused by na- QRS complex tachycardia with a left bundle tive heart ventricular tachycardia. An branch block morphology at a rate of 245 accurate diagnosis was made by selective beats/min. According to the standard ECG right and left sided electrocardiography. criteria1 he was diagnosed with ventricular Synchronised electrical cardioversion of tachycardia; however, the exact nature of the the native heart (200 J) resulted in resto- tachycardia remained obscure as narrow QRS ration of sinus rhythm with prompt relief complexes were interposed between the broad of symptoms and amelioration of the ones in the peripheral limb leads. Although clinical situation. these narrow beats during ventricular tachycar- (Heart 1999;81:323–324) dia could result from capture or echo beats, Keywords: transplantation; ventricular tachycardia they most probably reflected normal activation of the non-aVected heart. We wondered from which heart—donor or host—the arrhythmia A 51 year old man underwent heterotopic heart originated. In contrast to the left precordial http://heart.bmj.com/ transplantation because of end stage ischaemic leads (V2–6), the precordial V1 lead showed heart disease and fixed pulmonary hyper- sinus tachycardia; therefore an ECG in the tension. Two days after transplantation he was dextrocardia position was taken by positioning admitted to the intensive care unit because of the precordial leads rightwards on the chest. sudden haemodynamic collapse. His clinical This right sided ECG showed ventricular course had been uneventful, but he presented tachycardia in V1R whereas precordial leads with cardiogenic shock characterised by hypo- V2R–6R showed sinus rhythm (fig 1). As the tension (blood pressure 55/46 mm Hg), severe donor heart is positioned rightward to the on September 24, 2021 by guest. Protected copyright.

Cardiovascular Center, OLV Ziekenhuis, Moorselbaan 164, B9300 Aalst, Belgium M Vanderheyden J de Sutter M Goethals

Correspondence to: Dr M Vanderheyden, Cardiovascular Center, Imeldaziekenhuis, Imeldalaan 8, 2820 Bonheiden, Belgium. email: Marc.Vanderheyden@ skynet.be Figure 1 (Top) Standard 12 lead ECG. Precordial leads V2–6 show a broad QRS complex tachycardia compatible with native heart ventricular tachycardia whereas the precordial lead V1 shows sinus tachycardia of the donor heart. (Bottom) Accepted for publication Right sided ECG. When all precordial leads are swapped from the left to the right, ventricular tachycardia is noted in V1R 2 September 1998 whereas leads V2R–6R show sinus tachycardia originating in the donor heart. 324 Vanderheyden,de Sutter, Goethals

native heart, the small complexes on the ECGs implications of ventricular arrhythmias in most probably reflected normal activation of heterotopic heart transplant recipients.34 5 the donor heart, whereas the broad QRS com- Owing to the maintenance of haemodynamics Heart: first published as 10.1136/hrt.81.3.323 on 1 March 1999. Downloaded from plexes represented native heart ventricular by the heterotopic allograft, they are better tol- tachycardia. Synchronised electrical cardiover- erated and they do not carry the same risk of sion of the native heart (200 J) with one sudden cardiac death. defibrillator paddle under the left clavicula and The implantation of the donor heart to the the other on the left mid-axillary line at the right of the native heart allows selective ECG level of the 10th rib resulted in restoration of recordings of donor and host heart by examin- sinus rhythm with prompt relief of symptoms ing the precordial ECG leads from the right and amelioration of the clinical situation. and left chest, respectively. Therefore, when- ever heterotopic transplant recipients develop Discussion severe arrhythmias, a right sided ECG should Heterotopic heart transplantation has become be taken for the exact localisation of the a useful option for patients with end stage heart arrhythmia. disease and severe fixed pulmonary hyper- tension. These patients are denied orthotopic 1 Wellens HJJ, Bar FWHM, Lie KI, et al. The value of the heart transplantation as the thin walled right electrocardiogram in the diVerential diagnosis of a tachycardia with a wide QRS complex. Am J Med ventricle of the donor heart will not be able to 1978;64:27–31. sustain the sudden increase in right ventricular 2 Cochrane AD, Adams DH, Radley-Smith R, et al. Heterotopic heart transplantation for elevated pulmonary afterload imposed by the high pressures in the vascular resistance in pediatric patients. J Heart Lung pulmonary circulation of the recipient. There- Transplant 1995;14:296–300. 3 Greenfield RA, Sorrentino RA, Natale A. An unusual cause fore they are critically dependent on right ven- of ventricular fibrillation. Pacing Clin Electrophysiol 1997;20: tricular function and loss of the native right 732–4. 4 Neerukonda SK, Schoonmaker FW, Nampalli VK, et al. ventricular contribution will result in rapid Ventricular dysrhythmia and heterotopic heart transplanta- right ventricular failure and systemic tion. J Heart Lung Transplant 1992;11:793–6. 2 5 Kotliar C, Smart FW, Sekela ME, et al. Heterotopic heart hypoperfusion. Scarce reports exist regarding transplantation and native heart ventricular arrhythmias. the diagnosis, and clinical and therapeutic Ann Thorac Surg 1991;51:987–91. http://heart.bmj.com/ on September 24, 2021 by guest. Protected copyright.