Ectopic atrial tachycardia (EAT) is one of the most common forms of persistent supraventricular tachycardia in children. •  EAT is due to increased automaticity of a non-sinus atrial focus, and when leIt untreated can cause tachycardia-induced cardiomyopathy, also known as tachycardiomyopathy (TCMP). •  EAT can be difficult to distinguish from sinus tachycardia depending on the location of the ectopic focus.

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Diagnos(c Dilemma in Tachycardiomyopathy (TCMP)
Paige Sheaks1, Marc Anders1, Elena Montanes2, Michiaki Imamura3, Zhe Fang4, Hari Tunuguntla5, Asra Khan5, ChrisDna Miyake5, JusDn Elhoff1
CriDcal Care Medicine1, Cardiac Surgery3, Anesthesia4, and Cardiology5, Department of Pediatrics, Baylor College of Medicine, Houston TX and Hospital 12 de Octubre2, Madrid Spain
INTRODUCTION CASE REPORT DISCUSSION
• Ectopic atrial tachycardia (EAT) is one of the most
common forms of persistent supraventricular
tachycardia in children.
• EAT is due to increased automa(city of a non-sinus
atrial focus, and when leI untreated can cause
tachycardia-induced cardiomyopathy, also known as
tachycardiomyopathy (TCMP).
• EAT can be difficult to dis(nguish from sinus
tachycardia depending on the loca(on of the ectopic
focus.
HISTORY
• 16-year-old previously healthy male
presented with new-onset nausea, vomi(ng,
fa(gue, palpita(ons, and chest pain.
• Found to have severely depressed systolic
func(on (calculated ejec(on frac(on 22%)
and severe mitral regurgita(on.
• ECG revealing apparent sinus tachycardia with
a heart rate (HR) of 120bpm (Figure 1).
• Heart failure medically managed with
milrinone, furosemide, enalapril, and
intermiWent use of epinephrine.
• Despite symptoma(c improvement his HR
trended to 180-190bpm (Figure 2), with p
wave morphology and axis remaining
consistent with sinus tachycardia.
ARRHYTHMIA
• As his HR increased dispropor(onately and his
cardiac func(on further deteriorated, the
decision was made to perform an
electrophysiologic (EP) study.
• EP mapping study revealed an ectopic focus in
the posterior right atrium - radiofrequency
abla(on successfully performed with return of
normal sinus rhythm at rate of 110bpm.
• He remained in sinus rhythm post-abla(on
with HR between 70-100bpm
• His heart func(on ini(ally remained
qualita(vely severely depressed, with slow
improvement in func(on since discharge.
PROCEDURAL SUPPORT
• Due to pa(ent’s tenuous clinical status,
mul(disciplinary decision was made to place
an Impella device under conscious seda(on
prior to the EP study.
• An Impella CP device was successfully placed
via the right femoral artery and advanced to
the P8 se_ng to achieve a flow of 3.3 liters
per minute.
• He was managed on low dose inotropic
support and aIerload reduc(on for five days
before Impella removal.
• The tachycardia associated with TCMP may be
misinterpreted as a compensatory physiologic
response to acute heart failure.
• When the ectopic focus of the atrial tachycardia is near
the sinus node, the diagnosis may be delayed.
• It is important to keep a high index of suspicion for
TCMP in previously healthy pa(ents presen(ng with
acute heart failure/dilated cardiomyopathy, as the
systolic dysfunc(on of TCMP is poten(ally reversible
with appropriate heart rate normaliza(on.
IMPLICATIONS FOR
CLINICAL PRACTICE
• This case highlights the challenge of dis(nguishing an
atrial ectopic focus as the cause of TCMP in a pa(ent
who appears to be in compensatory sinus tachycardia
and the importance of keeping EAT in the differen(al
diagnosis for these pa(ents.
• In addi(on, this case highlights the u(lity and feasibility
of placing an Impella device in a consciously sedated
and spontaneously breathing pa(ent for cardiovascular
support while further interven(ons are pursued. Figure 1. ECG showing presumed sinus tachycardia.
Figure 2. Heart rate trend showing increasing rate un(l the (me of radiofrequency abla(on.