Bidirectional Ventricular Tachycardia: Challenges and Solutions

Abstract

Bidirectional ventricular tachycardia (BiVT) is a rare form of ventricular tachycardia that manifests on surface electrocardiogram by dual QRS morphologies alternating on a beat-to-beat basis. It was first reported in the 1920s as a complication of digoxin, and since then, it has been reported in other conditions including fulminant myocarditis, sarcoidosis, catecholaminergic polymorphic ventricular tachycardia, and Andersen-Tawil syndrome. The mechanism for BiVT is not as well known as other forms of ventricular tachycardia but appears to include typical mechanisms including triggered activity from afterdepolarizations, abnormal automaticity, or reentry. This review will go beyond the definition, surface electrocardiogram, mechanisms, causes, and treatment of BiVT as per our current understanding.

Unusual Tachycardia After Cocaine Use

“…1 It is a rare arrhythmia that is mostly caused by digoxin toxicity. Other causes include aconitine poisoning, catecholaminergic polymorphic ventricular tachycardia, and familial hypokalemic periodic paralysis, as well as in rare cases myocarditis, Andersen Tawil syndrome, ventricular tumors, fatty replacement of the ventricle, 2,3 exercise, 4 after radiofrequency ablation of ventricular tachycardia, 5 cardiac sarcoidosis, caffeine poisoning, 6 and pulmonary embolus Bidirectional ventricular tachycardia associated with acute and chronic ischemic heart disease in the absence of digoxin toxic effects was not described until the beginning of the 21st century. One case was reported in 2005.…”

“…2 Since then, to my knowledge, few cases have been reported in patients with acute infarction and ischemic cardiomyopathy. 3,6,7 The unique feature of BVT is the alternating QRS morphology and alternating frontal-plane QRS axis. Most cases show alternating QRS complexes in V 1 , both with atypical right bundle branch block morphology, that varies from 1 beat to the other.…”

“…Re-entry is the least likely to be the mechanism of BVT. 6 Treatment of BVT should consider the cause of the arrhythmia. Gastric lavage may be helpful in aconitine ingestion.…”

Elderly male with nausea and vomiting

“…It can also be caused by catecholaminergic polymorphic ventricular tachycardia (a genetic dysrhythmia induced by exercise, physical, or emotional stress), acute myocardial ischemia, ischemic cardiomyopathy, myocarditis, and cardiac sarcoidosis. 1 On further questioning, the patient admitted to overdosing on his apixaban, digoxin, and dapagliflozin 24 hours prior. His digoxin level was markedly elevated at 7.2 ng/mL.…”

“…An electrocardiogram (ECG) was obtained (Figure 1), which demonstrated a rare example of bidirectional ventricular tachycardia (BiVT), which is most commonly seen with digoxin toxicity. It can also be caused by catecholaminergic polymorphic ventricular tachycardia (a genetic dysrhythmia induced by exercise, physical, or emotional stress), acute myocardial ischemia, ischemic cardiomyopathy, myocarditis, and cardiac sarcoidosis 1 . On further questioning, the patient admitted to overdosing on his apixaban, digoxin, and dapagliflozin 24 hours prior.…”