Polymorphic ventricular tachycardia induced by modified Valsalva manoeuvre in a young woman: a case report

Introduction

The Valsalva manoeuvre is considered a safe and easy method for acute termination of supraventricular tachycardia (SVT) in hemodynamically stable patients, especially in case of a regular narrow QRS tachycardia. Therefore, guidelines recommend this manoeuvre as first line treatment (1). Adverse effects are rare; however, the manoeuvre is not completely free of potential side effects like chest pain, arrhythmia, or stroke (2). We report the rare case of a patient presenting with polymorphic ventricular tachycardia during a modified Valsalva manoeuvre. We present this case in accordance with the CARE reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-28/rc).

Case presentation

A 31-year-old woman experienced palpitations for approximately one hour. Similar episodes had occurred previously; therefore, she self-performed a carotid sinus massage without any improvement before calling the ambulance service. On arrival of the paramedics, the patient was hemodynamically stable and denied any syncope, dyspnoea, or chest pain. Her only significant medical history was a hypochromic microcytic anaemia due to iron deficiency and she took no medication. A 12-lead electrocardiogram (ECG) showed a regular and narrow QRS-complex tachycardia at a rate of 191 beats per minute with short-RP interval suggestive of atrioventricular nodal re-entrant tachycardia (AVNRT; Figure 1A). Intravenous access was established, and blood was drawn for a venous blood gas analysis that showed blood electrolyte concentrations within normal range. Afterwards, the patient was instructed to perform a modified Valsalva manoeuvre. After being repositioned with her lower extremities raised to 45° by the paramedics, the ECG showed the occurrence of a non-sustained polymorphic ventricular tachycardia (Figure 1B,1C) before converting to a stable sinus rhythm. During this episode, she remained responsive but reported feeling unwell with dizziness and chest pain.

Figure 1 Initial findings. (A) Twelve-lead electrocardiogram (50 mm/s) showing a narrow-QRS complex tachycardia. (B) Twelve-lead electrocardiogram (50 mm/s) during the episode of non-sustained polymorphic ventricular tachycardia. (C) Rhythm strip showing non-sustained polymorphic ventricular tachycardia induced by a modified Valsalva manoeuvre during a narrow QRS-complex tachycardia.

Further ambulatory examination of the patient was carried out as pictured in the timeline (Table 1): a 12-lead ECG showed sinus rhythm with normal conduction, normal QT-interval, and no visible pre-excitation (Figure 2A). A bicycle exercise test was performed up to 125 watts with no significant ST segment changes, a normal heart rate and blood pressure response, and without the occurrence of arrhythmic events (Figure 2B). High-lead ECG was performed and showed no signs of a Brugada-like pattern (Figure 2A). An echocardiogram showed a normal systolic and diastolic function with a slightly enlarged right ventricle. In suspicion of an arrhythmogenic right ventricular cardiomyopathy (ARVC), a cardiac magnetic resonance imaging study was performed without showing any pathological abnormalities. Finally, a cardiac computed tomography scan ruled out coronary artery disease, anomalous coronary arteries, and a myocardial bridge (Figure 2C). Due to an exclusion of a structural heart disease a 24-hour ECG monitoring, an electrophysiological study with the possibility to perform an atrioventricular node ablation, and genetic testing were recommended; however, the patient refused to undergo these procedures.

Figure 2 Clinical workup. (A) Left image: 12-lead electrocardiogram (50 mm/s) at rest; right image: high-12-lead electrocardiogram (50 mm/s). (B) Bicycle exercise test showing no significant ST segment changes and normal heart rate response. (C) Multimodal imaging (above: cardiac computed tomography scan ruling out a coronary artery disease; middle: normal magnetic resonance imaging study; below: normal ECG). ECG, echocardiogram; LAD, left anterior descending; LCX, left circumflex artery; RCA, right coronary artery.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report was not obtained from the patient or the relatives after all possible attempts were made. Due to a loss of follow-up and loss of contact a written informed patient consent could not be obtained.

Discussion

Both Valsalva manoeuvre and modified Valsalva are commonly performed with low rates of adverse events (3). Appelboam et al. reported four episodes of ventricular escape activity during the REVERT trial without further explanation of these episodes (3). Yet, similar events on polymorphic ventricular tachycardia induced by Valsalva manoeuvre have been reported (4-6). Only one of these previous reports contained a follow-up examination including an electrophysiological study that found a concealed accessory pathway (6).

In our case, a structural heart disease was ruled out by multimodal imaging techniques. An underlying electrogenic disease like long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT) and Brugada syndrome seemed unlikely due to the normal 12-lead ECG, the normal exercise test, and a normal high-lead ECG; however, these diseases cannot be excluded entirely due to a lack of a genetic test and an electrophysiological study.

In our opinion, polymorphic ventricular tachycardia following Valsalva manoeuvre should always be considered unphysiological and requires further examination. Furthermore, it is important to distinguish between a polymorphic ventricular tachycardia which is induced by bradycardia/atrioventricular (AV)-block or polymorphic ventricular tachycardia following tachycardia. With adenosine, for example, a ventricular salvo induced by an AV-block would be considered physiological, but a ventricular salvo following a tachycardia requires further examination.

A possible physiologic explanation for the polymorphic ventricular tachycardia could be a pre-existing subendocardial ischemia during the SVT followed by substantial fall in cardiac output due to the modified Valsalva manoeuvre which could have impaired the myocardial ischemia and thereby triggered the polymorphic ventricular tachycardia (4).

Conclusions

In conclusion, non-sustained irregular broad complex tachycardias may be seen rarely while performing a modified Valsalva manoeuvre during an SVT without necessarily being linked to structural heart disease. These events should be considered unphysiological and require further evaluation.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-28/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-28/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-28/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report was not obtained from the patient or the relatives after all possible attempts were made. Due to a loss of follow up and loss of contact a written informed patient consent could not be obtained.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2020;41:655-720. [Crossref] [PubMed]
2. Pstras L, Thomaseth K, Waniewski J, et al. The Valsalva manoeuvre: physiology and clinical examples. Acta Physiol (Oxf) 2016;217:103-19. [Crossref] [PubMed]
3. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015;386:1747-53. [Crossref] [PubMed]
4. Lapalme C, Kaw S, Drennan I, et al. Non-Sustained Polymorphic Ventricular Tachycardia Induced by Modified Valsalva in a Pregnant Patient with Supraventricular Tachycardia. Prehosp Emerg Care 2023;27:54-8. [Crossref] [PubMed]
5. De Mattia L, Brieda M, Del Bianco F, et al. Polymorphic ventricular tachycardia induced by Valsalva manoeuvre in a patient with paroxysmal supraventricular tachycardia. Europace 2012;14:767-8. [Crossref] [PubMed]
6. de Alencar Neto JN, de Moraes SRR, Neves JM, et al. Nonsustained polymorphic ventricular tachycardia following modified Valsalva maneuver: a case report. Case Reports: Open Access 2017. Available online: https://www.jscholaronline.org/articles/CROA/Non-Sustained-Polymorphic-Ventricular.pdf