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A case of vagally mediated idiopathic ventricular fibrillation


Background A 25-year-old woman experienced three episodes of syncope over the course of 2 years. The attacks all occurred just after she had sat down, and two were accompanied by convulsions. She had no obvious prodromes and no personal or family history of cardiovascular disease.

Investigations Electrocardiography, chest radiography, echocardiography, cerebral and cardiac MRI, electroencephalography, 24 h Holter monitoring, electrophysiological study with drug provocation testing and heart-rate variability analysis.

Diagnosis Vagally mediated ventricular fibrillation initiated by premature ventricular complexes arising from the right ventricular outflow tract.

Management Catheter ablation was performed at the right ventricular outflow tract and an implantable cardioverter-defibrillator was fitted.

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Figure 1: 24 h Holter monitoring recorded a total of 107 premature ventricular complexes, which occurred mostly when the patient was asleep (as indicated by the decrease in average heart rate).
Figure 2: Repeated 12-lead electrocardiography demonstrated bigeminal premature ventricular complexes (PVCs) with a left bundle branch block QRS pattern and tall R waves in the inferior leads.
Figure 3: Upon cessation of the tilt-table test, electrocardiography recorded single, couplet and triplet premature ventricular complexes followed by an 8-beat run of nonsustained polymorphic ventricular tachycardia.
Figure 4: Intravenous administration of 10 mg edrophonium chloride provoked premature ventricular complexes, as recorded on electrocardiography.
Figure 5: After an attempt to take a blood sample from the patient's arm, electrocardiography demonstrated a slowing of the sinus rhythm followed by a single premature ventricular complex which led to polymorphic ventricular tachycardia.


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The authors would like to thank K Fukumoto for his cooperation in collecting data, and J Annis for his linguistic advice.

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Correspondence to Seiji Takatsuki.

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Kataoka, M., Takatsuki, S., Tanimoto, K. et al. A case of vagally mediated idiopathic ventricular fibrillation. Nat Rev Cardiol 5, 111–115 (2008).

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