SVT or VT?

[sheshe00]

Background: During a run on Thanksgiving I ended up in tachycardia. Lucky for me an RN pulled over and took me to the ER. I was put on an EKG and my heart rate was at 260 wide complex tachycardia. The restarted my heart with Adenosine in an IV. I have had a cardiac MRI it has ruled out Hypertrophic Cardiomyopthy (I have a family history) and ARVD(the cardiologist thought I had ARVD based off my EKGs). The MRI showed no scar tissue and everything looks healthy. My cardiologist told me I had SVT and prescribed Flecanide. I have normal/low blood pressure. He told me the only way I would die is if I passed out in front of a bus. I then asked for an ablation. (My primary care DR told me to insist on one).

Turns out the cardiologist I saw was new and did not have operating privileges at the heart hospital. I saw a new cardiologist who said he did not think I had SVT based on my EKG from the emergency room. He said he had to assume VT and thinks I misunderstood my previous cardiologist (same practice). I did not misunderstand. I also found out from the new cardiologist that the cardiac MRI did show minor loss of functionality on my right side. I found out yesterday the halter monitor that I wore for three days prior to my cardiac MRI was never reviewed. I had always assumed it was normal. It had multiple episodes of tachycardia over a dozen. It also had two incidents of wide complex tachycardia at 200bpm and 231 bpm. The nurse said she was contacting her supervisor and my DR. I go in on 4 FEB for a EP. I was told that if it is SVT they will do an ablation, if it is VT they will do an ablation and a defibrillator, and if they cannot determine then I will get a defibrillator.  

I thought I was meeting the new cardiologist for a pre-op for just an ablation for SVT. I was totally thrown off guard. I dont know what to think I am back to having discussions about the priority being to keep me alive. How can I have VT with a healthy heart? How can I have SVT that is sustained at 230-260bpm?  I would like to know others opinions on if this sounds like SVT or VT. Everything I read says that if you have a healthy heart and VT then you do not need a defibrillator so why would my DR say I am getting one?  I have attached my EKG from the emergency room.

[sheshe00]

I did mean 77% effective in the long run but he did not differentiate between right and left VT. I believe he meant left VT since he was not expecting to find RVOT. He did fully map my heart during the EP study but he was unable to cause VT in my left ventricle.  Since I have had the defibrillator I have had multiple episodes of VT luckily nothing over 200bpm and nothing sustained. Have you ever heard of someone having VT in the left ventricle with no underlying heart condition? I asked about all the left VT that is genetic and he said it was none of those either. He said "rouge cells' in my left ventricle. I really like the guy but I'm with you on getting another opinion. He said it was complex and a process to see what to do next. Good news is that I have had no VT since starting the Sotalol. He said the real test is when I try to exercise. Is UPENN the best? My dad lives in Augusta, GA.

I want to say thank you for chatting with me. It has really helped me ask the right questions and figure out a path forward.

[researcher09]

I re-read your Feb. 1 post that referred to the 77% number and I mis-read it.  I thought you meant 77% success rate, you wrote "77% chance of not being successful in the long run" or 23% long term success.  I am so sorry I mis-read your post.  That is not good.  You need to find a different center for the ablation.  Top centers I listed earlier are getting much better than 70% success rates for simple VT's such as RVOT.

[researcher09]

Too bad the rvot ablation didn't take care of your VT.  It's hard to tell where the problem is exactly without a detailed electro-anatomic mapping (EAM for short done with a mapping catheter).  LV mapping-ablation is more complex than RV ablation just because the LV is more difficult to get to and navigate.  LV tissue is thicker and has pockets as well as delicate tendons that connect the mitral valve leaflets so an EP has to be skilled and practiced.  Because the ICD implant gets you out of acute SCD danger zone and buys you more time to look at next steps, I suggest doing a wider search in your region for ablation expertise.  Looks like UPenn is a reasonable distance from Norfolk and they handle the most complex cases.  There are also a couple of places (Emory and Medical College Augusta)  in Georgia.  I am not familiar with Duke.

[researcher09]

Thanks for keeping us up to date.  I am glad he was able to ablate the RVOT and get to non-inducibility end point.  RV outflow tract is anatomically at the top the the ventricle always so I think you may have misunderstood the EPs surprise of not finding anything closer to the apical location given your family history.  Hopefully, that did the trick for you but there is a chance like your EP thinks, that there is something else there he didn't capture during this first procedure.  Your risk of SCD is down to nil so I am happy that you caught this in time.

[sheshe00]

Since my last update I have had multiple incidents of VT. Since they reached 195bpm my defibrillator did not go off. It is set to start therapy at 200bpm. My DR believes they are from the apex of the left ventricle. He said "rouge cells" in my left ventricle. He put me back on Sotalol but still only the half dose because of my low blood pressure. He said if I continue to have episodes then he will do another ablation. He said even if he cannot cause the VT or see any scar tissue during the next EP he will do an ablation to the apex of the left ventricle anyways.   I am still working through this process but at least there is a plan and I have an ICD to protect me from any sustained VT. My ICD was set to record any VT over 188. I had some episodes of increased heart rate at 160 while sitting and I felt  lightheaded that lasted anywhere from 5-10 minutes that was not recorded by the ICD. He has changed the settings of the ICD to start monitoring everything above 150bpm to see what it is. He does not believe it is the left ventricle because of the lower bpm. He said it may be the RVOT again. He said I had no genetic heart issue with regards to the arrhythmia. I was worried for my children who are 3 and 5 since my family already has to be tested for Hypertrophic Cardiomyopathy. I think what bothers me the most is that I see nothing about people that have VT in the left ventricle when they have a healthy heart. It seems very random to me that I have this issue and that there is no explanation as to why my heart produces "random cells' in the left ventricle that cause VT.

[sheshe00]

I had the EP done on Thursday. He found RVOT. He told me it was very easy to induce and he actually had a hard time pacing me out of it. My blood pressure dropped from 100 to 70 the 5 times RVOT happened. He said the tissue causing it was in the upper part of my Ventricle which was unusual since it is usually found at the bottom. After the ablation he was not able to cause any SVT or VT. He told me that the EKG from my ER visit in November did not match the RVOT he caused during the EP. He said actually it was opposite. He believes the VT I had in November is in the Left Ventricle. Since he could not be certain he got the VT from November he placed a defibrillator.  He put me on Sotalol but has now taking me off since I had an EKG with long QT. He now wants me on no medication to see what happens. Today he said it was a process to see what happened in November. If it happens again we will have the data from the defibrillator. He said it was all speculation. He said the RVOT was very bad, because it was easy to cause without trying, he had a hard time getting me out of it, and he couldn't complete the study without first doing the ablation to the RVOT. He said perhaps the incident in November started out as RVOT and ended up affecting the rhythm of the rest of the heart. He just does not know. I guess time will tell.

[researcher09]

Having the ICD as a back up is a good idea and standard of care with your family history.  ARVD is caused by anomalous fat tissue where heart muscle should be and depending on the extent, maybe hard to define even with MRI so I can understand your EP wanting to have the ICD backup.  You can ask him about removing the ICD after a year with no recurrences.  If the EP gets 77% overall success rate on all types of VT with 5% or lower major complication rate, he is doing reasonably well.  The hardest VT cases are those for post heart attack patients with lots of scarring.  RVOT is on the simple end of the scale as far as VT ablation goes.  If ARVD is present, that would make the case harder to ablate, thus the ICD back up.

[researcher09]

The 77% success rate for RVOT ablation quoted to you is about right for tertiary referral centers.   The top centers are getting around 90% and you can skip the ICD implant if you get a successful procedure.  They can tell whether it worked or not by trying to induce a VT after the ablation while you are still in the EP lab.  Non-inducibility would be the end of the procedure.   Was he giving you the success and complication rate for the Sentara EP clinic?  

[sheshe00]

I thought he was giving the success rate for VT in general at least that is how he said it. He would do the ablation if I had VT and he would ensure he could not induce another episode of VT. He would put in a defibrillator anyways as backup to the ablation because the ablation had a 77% chance of not being successful in the long run. He did not specify to me which type of VT he thought I had. I am assuming it is RVOT given I was able to treat it with adenosine and I had indicators of ARVD.

[MichelleP_3811]

I tend to low bp myself and find it best to have eaten before getting on the elliptical.  SVT can make it feel like you will pass out but you generally don't.  I always had to lay down with mine until I started to exercise regularly then I was able to sit up and even move around a bit though that was a bit taxing on my heart so I would not suggest it.  Holding your breath and bearing down like straining to go to the bathroom, coughing or drinking a cold glass of water may help.  I would also suggest getting more sodium in your diet if you tend to low bp and drink plenty of water to help your heart function better in general.  Well best of luck Thursday.  I will keep you in my prayers and do hope that it turns out to be an easy to fix svt.  Please let us know how it goes when you feel up to it.  Hugs.  

[is_something_wrong]

Sustained VT at 260 bpm would more likely cause more severe symptoms than SVT. Typically, VT does not respond to adenosine as it doen't involve the AV node. RVOT VT can sometimes respond to adenosine.

Luckily, you have an EKG from during the arrhythmia, and a skilled EP doctor cound fairly easy determine if it shows SVT or VT. Regardless, unless you had symptoms like fainting during the event, the heart was able to maintain your blood pressure, which means that sudden death is less likely. An arrhythmia is rarely dangerous if you remain hemodynamically stable during the event.

[sheshe00]

I wish this was more clear cut before I go in on Thursday for the EP. During the episode I could not walk or sit up,  because I was starting to blackout. The strange thing I had was my neck hurt and I couldnt hold up my own head.  My EKG shows both SVT and VT. I spoke again to my cardiologist on Friday and he said he was convinced it was VT even with the indicators of SVT. My previous cardiologist was convinced it was SVT. I have had two other cardiologists review the EKG and they both think it is VT. I have had episodes before where I got very light headed and it dropped me to my knees but it always fixed itself. I also passed out once a few years ago while on an elliptical. I had just started and I say my heart rate go up to 200 and I woke up on the floor. At the time I did many tests and they found nothing. I failed a tilt test and was told I had POTS. I had all of this while being seen at the same practice. I also tend to have normal to low blood pressure especially when I was pregnant. 90/70

Like what you said I feel like it was fixed with adenosine so probably not VT (I'm hoping). Also I have had episodes for 5 years just not like this last one. Everything I read is at odds with what the last three cardiologists are telling me. I guess I need to stop trying to control everything and wait till Thursday for the EP and then I will know.  

[sheshe00]

the other issue that confuses me is that I had signs of ARVD on my follow up EKGs which was then ruled out by a cardiac MRI so it very well could be RVOT. Except what I read about RVOT does not involve a defibrillator just and ablation. My cardiologist told me that ablation alone was only 77% effective for VT. He didnt specify what kind of VT. I should have asked.

[researcher09]

Questions to ask -
How many VT ablations has he done in total?
How many of those required epicardial ablations? (20% chance needed in your case)
How many does he do per year now?
What is his success rate, acute and chronic?
What is his major complication rate?

[sheshe00]

Thank you this is good to know. My Dr is a EP cardiologist for the procedure but I did not ask how many VT procedures he has done a year. I will ask today. Thank you,

[researcher09]

I am referring to the electrophysiologist who is going to do your ICD implant and ablation if they are one and the same.  Many general cardiologist do ICD implants.  Ablations are strictly performed by electrophysiologists which takes a lot of additional training beyond general and interventional cardiology.  50/year just refers to VT ablations.  If a specialist does 50 VT ablations, he would also do many more less demanding ablation procedures such as SVT and AF.  The are experts that just focus on VT/PVC ablations that do 150 per year and they will not have time left over for simpler procedures and the simpler ones will be handled by somebody else in the practice group.

[sheshe00]

Are you talking about my cardiologist doing 50 EPs a year or the heart hospital?

[researcher09]

I meant minimum 50 VT ablation procedures/year as it relates to expertise.

[researcher09]

Sorry,  Don't know the center or the EPs there at all.  As far as ICD implant, most heart and vascular centers will know how to do that reasonably well.  As for VT ablation, completely different skill set so you will want to know how many the EP does per year and his success and major adverse event rate.  You them to ask them directly.  The EP needs to do a minimum of 50 procedures to be considered a competent expert in VT ablation.  The list I have above are EPs that do over 100 VT ablation procedures/year in addition to their access to robotic magnetic navigation.  The latter tool is way better than hands for complex ablations of which VT ablation is the most complex of all.  I can think of 2 other places that have top hands, Emory and Harvard (Brighams and Women) but they don't have the magnets yet.

[sheshe00]

Do you know anything about Sentara Heart Hospital in Norfolk?

[researcher09]

Sorry about the repeat, the first post disappeared and now it is there.

[researcher09]

The EKG shows VT.  Given your family history of sudden death, what the EP is suggesting is the standard of care, ablation plus ICD implant.  Because the ablation is not simple and highly dependent on the skill and experience of the EP.  The ICD will protect you from SCD nonetheless so you will have choices later on even if the ablation is unsuccessful.  I am glad you caught this in time and best wishes for a completely successful outcome.  Let us know how things go.

[researcher09]

That sure looks like VT and not SVT.  Given your family background with SCD, it would be best to follow EP suggestion and get an ICD.  The optimal treatment would be ablation plus ICD and the ablation is complex so hopefully your EP is skilled and experienced with VT ablation.  Once the ICD is in, you will have more choices even if the ablation is not successful.  You will want to have a successful ablation in addition to the ICD.  The closest centers of excellence (the ones that handle the most complex cases at sufficient volume) include -
Medical College of Georgia (Augusta, GA)
University of Oklahoma  (Oklahoma City, OK)
Intermountain Medical Center (Murray, UT)
St. David’s Medical Center (Austin, TX)
The University of Kansas Hospital (Kansas City, KS)
U of Penn (Philadelphia)
Mount Sinai, Columbia U (NYC)

I am glad you caught this in time.

[MichelleP_3811]

All I will say is that SVT doesn't kill.  It is extremely rare for it to cause death and usually only with someone with other underlying issues.  Right ventricle dysfunction is a sign of AVRD so though it has been ruled out it sounds like the issue with the right ventricle may be what is causing you to drop into the tachycardia.  SVT also generally does not cause someone to pass out.  I felt like I would but never did.  I am not sure about POTS because that may involve low blood pressure issues but SVTs caused by extra pathways generally don't cause a person to pass out from what I understand.  The exception may be WPW because that kind of tachycardia involves both the ventricles and atria but usually there is a telltale sign even on a normal ekg that would suggest WPW but that may be what they don't want to rule out at this point.

Honestly if the doctors have that much concern then I would take them seriously and view this as a dangerous rhythm which is usually a VT situation.  And I will also say that if there is heart disease, problems with the right ventricle, then a simple ablation may not correct the issue.  The VT or whatever kind of tachycardia you are having could reoccur because the heart is pumping out of balance and it will throw the heart off and the tachycardia occurs as a consequence so a defibrillator may be necessary.  In general cardiologists do not generally rush to judgment.  They usually err on the side of caution and would not put a shocking device in a person unless they deemed it absolutely necessary.  So if you picked and trust your doctor and have good reviews about the facility I would follow their advice.  

As for having others on the site that have a similar situation I would not worry too much.  Many people come and go.  Stop by when they have an issue and leave once they are fixed so that doesn't mean there hasn't been anyone else in your shoes just that they may not be active at this time.  I wish you the best of luck with your ablation.  Please let us know when it is and I will keep you in my prayers.  Take care.

[sheshe00]

Hi Michelle, I did do a cardiac MRI and it ruled out ARVD and Hypertrophic cardiomyopthy. I have a family history of sudden death and one autopsy of my nephew with Hypertrophic Cardiomyopthy. I did have loss of function on my right side (cardiac MRI).

I had a health heart otherwise no scar tissue. I had a 3 day heart monitor that showed multiple tachycardia event (dozens). It also showed wide complex tachycardia 200bpm and 231bpm originating from the right bundle branch.

My cardiologist says the EKG shows VT but that you cannot diagnosis by the EKG and he will make the final diagnosis during the EP. I am told that because I am now high risk for sudden death I cannot wait to do the EP. I just had not seen anyone else who goes into an EP without knowing if it is SVT or VT. From what I read it seems you can have SVT with aberrancy that will show as wide complex. When any DR or Staff sees my ER EKG seems thing to get serious.

If I wasn't so worried about dropping dead I would go see someone in another practice but at this point I feel like I am risking too much to put it off any longer. I have talked to multiple friends who know people that work at the heart hospital and all of them had said good thing about my current DR.

It bothers me that no one online seems to have the same story as me. I will let you know what happens. He did say if he can cause neither SVT of VT in the EP he will give me a defibrillator because he said the type of tachycardia I had would kill me (as he pointed back to my EKG).

[sheshe00]

Thank you for commenting it really does help to talk with people about this.

[sheshe00]

I did choose my cardiologist. This is my third cardiologist the last two were electrophysiologists.  My 3 day monitor showed several incidents of tachycardia and two incidents of wide complex tachycardia 200bpm and 231bpm. I felt nothing I thought there were no incidents when I wore it. I am being told it is because I had wide complex tachycardia at 260bpm in the ER that did not fix itself on its own that I need to do the EP ASAP. The cardiologist told me his number one priority was to keep me alive his words not mine. I feel I cannot wait for another opinion given that I was told I am currently at risk for sudden death. I was told by both cardiologists and my primary care DR that had I not gotten to the ER when I did I would have died. My primary care also said I cannot wait to go in for the EP that if it were him he would not have waited as long as I did given the risk. I agree a lot sounds like SVT because even SVT may need trips to the ER if it is sustained. Plus I was seen 5 years and 3 years ago for  racing heart and passing out. They found nothing and told me I had POTS. What I do not understand is why does my EKG make everyone freak out and make them think it is VT. I was told my EKG is unusual and they were keeping it for training. My EKGs that have been done post ER visit indicated ARVD which was ruled out in a cardiac MRI. What confuses me the most is that everything I read says SVT is not deadly then why then would I end up in the ER and told if I hadn't come I would be dead? I agree with you nothing adds up that is why I posted to this site. I was told he would have to cause the arrhythmia in the EP to make a definitive diagnosis of SVT or VT. He said he had to assume VT until proven otherwise. He also said my EKG indicated VT. I was hoping someone else had had a similar experience.

[MichelleP_3811]

I am no ekg expert but the strip looks quite like vt to me. VT that sustains is a danger because if it isn't converted it could lead to cardiac arrest and death.  It is generally not a danger if it is short lived and stops on its own.  It doesn't sound like that was the case.  But I agree with Tom that rushing into an ablation or any medical procedure is not a wise thing.  I would get the monitor results to see what they say and consider consulting with an ep outside the practice that you have been seeing for a second opinion.  SVT is generally seen as narrow complex. VT is generally seen as wide complex.  But it can be a bit confusing with the terminology.  VT can be called NSVT while SVT can also be called PSVT.  They all to some degree sound the same so it can be easy to misunderstand a doctor when they talk fast and you are not feeling well.  I'm not saying you did misunderstand but it can be easy to misunderstand.  Usually most misunderstand and think they have VT but really have SVT.  It is possible to have both though.  But if your ekg does not indicate SVT it would likely be AVRD than SVT in my opinion.  Considering your family history and the fact the other doctor considers the possibility of right ventricle function issues it is a possibility that needs to be confirmed in my opinion.  So would ask for further test to determine the health of the heart.  Maybe a cardia mri if you haven't had one.  And I would definitely seek a second opinion before having a defibrillator put in.  I would however, seek treatment at an er if you ever get the tachycardia again.  Your strip leaves too much to question in my mind to wait it out like I could do with my svt.  I personally think an ablation is a wise decision at some point but do agree that further consultation with an impartial party may be in order.   You want to go into an ep study and ablation with confidence in what is going to happen and who is doing the procedure.  Best of luck.  Keep us posted on how you are doing.