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Forum Name: Arrhythmias

Question: 13 year old girl Holter Monitor results help!


 bigbird06 - Mon Jan 12, 2009 1:23 am

My 13 year old daughter used to be very outgoing and active. She was even cheerleading captain this past year. However, about 4 months ago she started changing. She started complaining about being dizzy all the time. One day she fainted in the kitchen floor. A tilt table test showed that her BP drops when she stands. It was recommended that she just increase her salt intake. She complains of being dizzy a lot, has chest pains, blacks out, short of breath and fatigued all the time. She has problems making it through PE class. She wore a holter monitor for 24 hours, but she didnt do normal activities while wearing it because we were out for snow. Here are her results from that test. Can you help me in understanding what is going on with her. She doesn't act anything like her old self. The dizzyness and fatigue control her life now.

average heart rate: 83 BPM
6 pauses exceeding 2.0 seconds were noted.
298 ventricular ectopics noted.
VE: 14 couplets and 3 runs....some of the ventricular beats occured in bigeminal cycles.
805 supraventricular ectopics were noted. 112 couplets, and 35 runs noted.


Please help me understand these. She has an appointment with an electrophysiologist in a few weeks. What is causing her to be so fatigued?
 John Kenyon, CNA - Mon Jan 12, 2009 9:28 pm

User avatar Hello -

Well, the tilt table test was more revealing than the Holter monitor, but together they explain a lot. The tilt table demonstrated possible neurocardiogenic syncope (NCS), a problem with the apparatus that regulates the blood pressure and heart rate so that one is able to stand up without all the blood pooling in one's abdomen and legs. This can be treated with medication if necessary. It's not serious at all, but can be awfully disruptive.

The Holter report is fairly non-revealing, except that in additon to the above issue there is a lot of ectopy (premature heartbeats) arising from both the upper and the lower chambers. There were several rather long pauses, presumably sinus pauses, which may be normal for someone her age (sinus arrhythmia, affected by breathing patterns, slowing down during inspiration and picking back up during exhalation); there were also a few triplets, three-beat "runs" of what is technically (and arbitrarily) ventricular tachycardia; more of these PVCs occurred in pairs or as bigemeny, which simply means every other beat is a premature beat for an indefinite period, which usually causes there to be more on the recording than would be otherwise, but basically means nothing; there were, most interestingly, lots of premature atrial contractions, apparently a whole lot of them coming in "runs" as well, although the duration of those isn't noted (usually because they are considered relatively benign), but there were 35 such runs of supraventricular tachycardia. If this is happening off and on during the day, this could cause a lot of symptoms including lightheadedness, dizziness, feelings of presyncope or actual fainting, fatigue, interruption of exercise tolerance (that is to say, exercise is well tolerated until this happens, at which point it may interrupt the ability to carry on the activity til it stops).

Since there are a number of things, some of them relatively normal and some a little bit problematic, the consult with the EP specialist makes eminent sense. The EP doctor can sort out what's causing these things, if they are related, and what can be done to manage or correct them. Some of this stuff that showed up really is normal and doesn't pose any sort of problem. The triplet runs of premature ventricular contractions (PVCs) may raise an eyebrow, but if there's nothing structurally wrong and these are tolerated well, they probably have little to no significance. The runs of supraventricular tachycardia (SVT), however, could be causing a lot of the problem -- a lot of the symptoms -- and this is something that can definitely be fixed, either by medication or, more effectively, via radiofrequency ablation (RFA). This latter will no doubt be offered as a possible way of correcting the problem, and is the most effective and most permanent way of correcting that particular problem. This may be at the bottom of the suspected neurocardiogenic syncope (which I am assuming was part of the tilt table finding -- though it may have not actually showed upthat way).

Basically the Holter monitor report shows a lot of random activity, most of it not very unusual, but with a lot of runs of SVT, which could be the cause of all the problems. It's also possible there is more than one thing going on, and both NCS and SVT can be treated medically the same way. However, the SVT part is best corrected permanently (which is the rule, although sometimes an RF ablation does fail to "take" -- rarely) and could possibly resolve all the problems at once.

Since the symptoms are so marked, I feel it would be foolish of me to speculate beyond what I've thrown out here prior to the EP consult. That should really clear up a lot of questions, as there are any number of electrical anomalies that could be causing this, most of them fairly simple to correct or treat. I hope you'll update us following the consult, and of course please follow up with us here at any point as needed.

I hope this is helpful to you. Best of luck to you and your daughter.
 bigbird06 - Tue Jan 13, 2009 12:52 am

Thank you so much for your post. It helped put things in a better perspective. I forgot to add that during the Ventricular runs her heart rate was always above 190 and during the svt episodes her heart rate ranged from between 117 and 197. The longest svt run was 98 beats. Is it normal to have both vt and svt?
 John Kenyon, CNA - Tue Jan 13, 2009 12:25 pm

User avatar You're very welcome.

The runs of V-tach were only triplets, so were all very short bursts. This happens a lot in young people and often goes unnoticed. The longest SVT run of 98 beats would have been one which would, depending upon the speed, have been long enough to notice and maybe even cause symptoms.

VT is often well-tolerated in healthy young people, and if there is no structural disease or electrical abnormality (such as long Q-T syndrome) then it often passes in the shuffle, unlike sustained runs of SVT.

While SVT is usually the complaint most registered in otherwise healthy young people with symptoms, it's not unheard of to have both VT and SVT show up, especially if there's an electrical abnormality or (especially) in cases of mitral valve prolapse (MVP) with symptoms. This may well be the case, even though the actual prolapse sometimes cannot be visualized and so doesn't get listed in the diagnosis. All this should come to light during the EP consult and study. There are a number of other heritable problems that also can cause this sort of array of signs and symptoms. Usually they are more an annoyance than anything else, but obviously can also cause a lot of anxiety and disruption.

I hope this further clarifies things, and please keep us updated.
 bigbird06 - Wed Jan 14, 2009 3:22 pm

I think I am starting to see a connection now. When she was in second grade she would have episodes where her she would have chest pains and her heart would be beating so hard that it would bounce your hand off her chest. The family doctor said that he heard a "click" and that he believed she had MVP. He referred her to a cardiologist. However, the cardiologist said that he didn't think she had MVP because the echo cardiogram showed only a trace amount of mitral regurgitation. Since then though, the family doctor and her pediatrician both hear (not all the time though) the standard "click" that is associated with MVP.

What would the treatment be for the MVP if that is in fact what is causing all of her problems?
 John Kenyon, CNA - Thu Jan 15, 2009 12:40 pm

User avatar The "click" murmur, which is pretty much a classic sign of MVP, can be variable. There are times when it is heard only rarely, while if one gets lucky it will be heard by more than one doctor, which is more convincing. As to the regurgitation factor, this is usually only trace or mild with MVP anyway, and the condition is extremely common. It is rarely a serious or progressive problem, although with a certain small subset it can cause more troublesome issues over time. It certainly is typical of MVP to be associated with the sort of "galaxy" of symptoms such as your daughter has been having, which occur in some and not in others. It's also not clear in all cases just why these symptoms occur, since they don't as a rule seem to have much of a direct connection with the mild valve abnormality, but arise from the autonomic nervous system (which, interestingly, develops in utero at about the same time as the mitral apparatus.

When MVP syndrome is treated at all, it is usually first with a beta blocker drug, and if there is persistent atrial tachyarrhythmia, sometimes with a calcium channel blocker as well, or sometimes with radio frequency ablation if there is an associated electrical issue involving redundant nerve tissue causing an unwanted conduction pathway. Everything else is largely a matter of teaching accomodation of the symptoms, keeping well-hydrated, and following a progressive aerobic exercise program as tolerated.

In the case of the rare progressive problem with the valve, it may (and I can't stress enough how unusual this is compared with the total number of documented MVP patients) eventually require replacement with a prosthetic valve. I only mention this because there is that very small subset of patients with connective tissue disease who eventually experience progressive problems with the valve. The vast majority do just fine, especially with the combination of medication and learning to live with what is essentially an occasionally major annoyance.
 bigbird06 - Fri Jan 16, 2009 1:04 am

Ok my daughter had her appointment with the EP doctor today. Her pediatrician was concerned about how she seems to be getting weaker so she pushed to get us in quicker. He explained that there are 3 main types of SVT and that 85% of people who have SVT fall into the 1st type. 10% have the second type. And that only 5% have the more rare; Atrial Ectopic Tachycardia. He said that the Atrial Ectopic is what he believes she has. He is supposed to call me tomorrow with the appointment date to do the EP study.
He said that he is concerned about what the damage the AET will do to her heart long term since her symptoms have become so complex in just four months. The doctor said that this particular arrhythmia is usually drug resistant in teens. He is going to try to do the RF ablation. However, he said that it is not always successful when treating AET and sometimes the second attempt isn't successful either. He said they will only try the RFA twice.
Does this sound pretty typical to you? I am glad to finally have some answers but it still leaves a lot of questions. If it is drug resistant and the RFA doesn't fix it, what would happen then? Because he makes it sound like heart failure is what will happen if we don't get this under control.
 John Kenyon, CNA - Fri Jan 16, 2009 8:03 pm

User avatar That explains a lot. This isn't something that comes to mind quickly -- at least not to my mind -- and maybe because I've never actually encountered anyone with this particular form of SVT in "real" life. I had actually imagined it was most likely the second type, which is itself relatively rare. AET is quite rare, and for some reason it's associated with weakening and dilation of the left ventricle, although why isn't clear. It's probably also not important, at least in the short term. What is is to get the arrhythmia abolished or at least managed.

RF ablation for this form of SVT has, based on my (abstract) knowlege of it, a success rate of 75-100%, which is pretty good. There are a number of doctors who would rule out a third attempt if the first and second failed to obliterate the Arrhythmia, and with this one being more resistant to the usual treatments, that would make sense. It does, however, respond to some of the more exotic and less-used medications, so that if a first and second ablation attempt were to be unsuccessful (or even less than successful), there are several very good medications available to manage it in whole or in part (depending on the outcome -- which of course is still more likely to be fully successful).

We'll be anxious to hear how this all unfolds. Thanks for the update, and it certainly does make sense. I hope the ablation can be performed promptly and that it is very successful. Please let us know how things go.
 bigbird06 - Mon Apr 27, 2009 11:48 pm

Hey. I just wanted to update and get your opinion.
My daughter had her EP study and RF ablation on March 2nd. It took about 3 1/2 hours to do the procedure. When it was over, the dr came out and said that they burned 2 spots and that he thought he got it all.
However, 5 hours after the surgery, her monitors started going off and showing that she was having SVT. They told me to give it a week and then things would be ok. Well here it is almost 2 months later and getting worse. Her pediatrician was concerned because she is starting to get really symptomatic again (dizzy, fatigued). When she exercises she gets really short of breath and feels like she is going to pass out. When I put my hand on her chest it feels like its bubbling or fluttering. I've never felt that before. Anyway, her pediatrician put her back on the holter monitor and this is what it says now...
260 supraventricular ectopics
9 venticular ectopics
34 isolated supraventricular events
7 couplets
17 runs
minimum heart rate was 50 bpm
fastest heart rate was 283 bpm

Ok, now my questions. What are your opinions about these results? Should we repeat the ablation? And, why does it seem like she is becoming more symptomatic as the time goes by. She complained just a little after the surgery but I notice that she is starting to get like she was before.

Thanks!

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