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ECGs and Pacemakers

Belhassen Ventricular
Tachycardia: A Case Study
Lauren Weaver, RN, MS, CNS, CCRN, CCNS
Michelle Curry, RN, BSN
Linda Schakenbach, RN, MSN, CNS, CCRN, CWCN, ACNS-BC
Kathleen Yakobitis, RN, BSN

PRIME POINTS

Many patients with

Belhassen ventricular
tachycardia experience
no signs or symptoms
with episodes of tachycardia.

Belhassen ventricular

tachycardia occurs more


often in males 15 to 40
years than in females of
those ages.

Nursing care includes


monitoring for dysrhythmia and its effects,
assisting patients with
treatment procedures,
administering medication
and monitoring its
effects, and providing
discharge education.
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patient who had experienced ventricular


tachycardia was admitted to the coronary
care unit (CCU) in
normal sinus rhythm. According
to the admitting physicians notes,
the dysrhythmia presumably was
caused by myocardial ischemia.
The dysrhythmia was described as
paroxysmal sustained ventricular
tachycardia with a left posterior
fascicular block. After coronary
artery disease was ruled out, an
electrophysiologist diagnosed Belhassen ventricular tachycardia.
The prevalence of Belhassen
ventricular tachycardia is not known,
and little is available in the literature
on the care of patients with this
abnormality. In this case study, we
summarize the information in the literature, present the case study, and
describe the nursing care provided.

Summary of the Literature


Belhassen ventricular tachycardia is a unique ventricular tachycardia (also known as idiopathic
fascicular ventricular tachycardia,
2010 American Association of CriticalCare Nurses doi: 10.4037/ccn2010398

verapamil-sensitive ventricular
tachycardia, and reentrant left ventricular tachycardia) first described
by Bernard Belhassen and colleagues
in 1981.1 Belhassen ventricular
tachycardia occurs more frequently
in males 15 to 40 years old than in
females of the same ages, and it may
occur more commonly with exercise
than at rest.2 Although approximately
90% of ventricular tachycardias
occur in patients with anatomically
abnormal hearts,2 most patients with
Belhassen ventricular tachycardia
have anatomically normal hearts
hence one of the names: idiopathic
fascicular ventricular tachycardia.
The dysrhythmia may involve slowcalcium-channeldependent tissue
or a reentry mechanism of the distal
fascicles of the left bundle branch.3
Patients with Belhassen ventricular tachycardia may experience no
signs or symptoms. Those who do
have signs or symptoms most often
report shortness of breath, fatigue,
or dizziness. Syncope and sudden
death are extremely rare.2
The diagnosis is based on the
unique electrocardiographic (ECG)
features of the ventricular tachycardia: paroxysmal, usually with a left
posterior fascicular block, a right

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bundle branch block, and left axis


deviation (Figure 1).
Treatment can be ablation or
pharmacological therapy. The ventricular tachycardia may be difficult
to induce during electrophysiological
studies, with or without pharmacological provocation. Some investigators5-7 suggest that induction of
Belhassen ventricular tachycardia
may be more difficult after pharmacological intervention and recommend
ablation as the initial treatment. If
the ventricular tachycardia can be
induced, radiofrequency ablation may
be performed. For younger patients,
because of the potential need for
long-term antidysrhythmia therapy
and the possible side effects of the
medications used, ablation is the
preferred treatment.5 Typical pharmacological treatment is verapamil.
Intravenous verapamil has been effective in treating the ventricular tachycardia, and oral verapamil has had
variable results in preventing recurrences.5 Propranolol (Inderal) has
been effective both in treating Belhassen ventricular tachycardia and in
preventing recurrences. Vagal maneuvers may also be effective. Use of
adenosine has not been successful.

Anterior fascicle of LBB

Posterior fascicle of LBB

RBB

Septal
fascicle
of LBB

Figure 1 The intraventricular conduction system shown through transparent walls.


Reprinted from Conover,4 with permission from Elsevier Mosby, copyright 2003.
Abbreviations: LBB, left bundle branch; RBB, right bundle branch.

Case Study
A 73-year-old man came to the
emergency department because of
intermittent dizziness and near-

Authors
Lauren Weaver is a clinical nurse specialist in surgical cardiac nursing, Inova Heart and
Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia. She was a graduate
nursing student at Georgetown University, Washington, DC, at the time of manuscript
preparation and a registered nurse in the medical intensive care unit at Georgetown University Hospital.
Michelle Curry was a registered nurse in the coronary care unit, Inova Heart and Vascular
Institute, Inova Fairfax Hospital, Falls Church, Virginia, at the time of manuscript preparation.
Linda Schakenbach is a clinical nurse specialist in medical cardiac nursing, Inova Heart
and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia.
Kathleen Yakobitis was a registered nurse in the coronary care unit, Inova Heart and Vascular
Institute, Inova Fairfax Hospital, Falls Church, Virginia, at the time of manuscript preparation.
Corresponding author: Linda Schakenbach, RN, MSN, CNS, CCRN, CWCN, ACNS-BC, Inova Fairfax Hospital/Inova Heart
and Vascular Institute, 3300 Gallows Rd, CCU, Falls Church, VA 22042-3300 (e-mail: linda.schakenbach@
inova.org).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

syncope. Some of the symptomatic


episodes occurred with activity, but
others occurred while he was sitting
in a chair. For 2 to 3 weeks before he
came to the hospital, he had experienced shortness of breath after as
little as 15 minutes of walking. He
had been experiencing the dizziness
and near-syncope for 1 to 2 days.
He described associated symptoms
of 2/10 chest pressure, nausea, shortness of breath, and paresthesias of
both upper extremities. Vital signs
were normal, with heart rate 80/min,
blood pressure 134/72 mm Hg, respirations 14/min, and oxygen saturation 99% by pulse oximetry.
The patients medical history
included hypertension, hyperlipi-

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demia, osteoporosis, gastroesophageal reflux disease, benign prostatic


hypertrophy, allergic rhinitis, and
childhood asthma. He had smoked
2 packs of cigarettes a day for 25
years until he quit 30 years ago. His
surgical history included knee replacement, hip replacement, cervical
spine surgery, cataract surgery, and
3 transurethral resections of the
prostate. Before this admission, he
had worked 3 days a week. He said
he had experienced episodes of
dizziness for at least the previous 50
years; he thought the dizziness was
related to the hypertension. His
medications included the following:
Alendronate (Fosamax) 70 mg/wk
Amlodipine (Norvasc) 5 mg/d
Lisinopril 10 mg/d
Olmesartan (Benicar) 40 mg/d
Simvastatin (Zocor) 20 mg/d
Aspirin 81 mg/d
Calcium supplements, dose
unknown
The patient was allergic to chocolate, lobster, and strawberries. The
only reported family history of note
was the death of his father at age 50
years due to myocardial infarction.
In the emergency department,
cardiac monitoring showed ventricular tachycardia. The initial treatment was intravenous lidocaine.
The cardiac rhythm changed to sinus
bradycardia at 50/min to 60/min
with bigeminy. The patient was
asymptomatic. Findings on chest
radiography were normal. The results
of laboratory studies were within
the reference ranges except for slightly
low serum levels of calcium and
magnesium (see Table).
The patient reported that because
of his shortness of breath, he had
had cardiac nuclear imaging a few
weeks before admission. The results

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Table

Results of laboratory studies

Parametera

Value
Normal range

Patients value

Hematocrit, male, %

42-52

40.5

Hemoglobin, male, g/dL

13-17

14

3500-10 800

7400

Platelets, male, x10 /L

140-400

272

Sodium, mEq/L

136-146

128

Potassium, mEq/L

3.5-5.3

4.4

Chloride, mEq/L

98-107

94

Carbon dioxide, mEq/L

21-30

25

Urea nitrogen, mg/dL

8.0-20

18

Serum creatinine, mg/dL

0.6-1.5

1.1

<140

127

White blood cell count, male, cells/L


3

Glucose, mg/dL
Calcium, mg/dL

8.6-10.2

8.4

Magnesium, mEq/L

1.48-1.89

1.32

Troponin I, ng/mL
Stat
Quantitative

0-2.0
0-2.0

0.02
0.03

0.9-1.1

1.0

International normalized ratio


a SI

units: To convert urea nitrogen to mmol/L, multiply by 0.357; serum creatinine to mol/L, multiply by
88.4; glucose to mmol/L, multiply by 0.0555; calcium to mmol/L, multiply by 0.25; magnesium to mmol/L,
multiply by 0.50.

of that imaging indicated inferior


wall scarring.
Three hours after he came to the
emergency department, the patient
was admitted to the CCU; the diagnosis was acute coronary syndrome
and dysrhythmia. ECG monitoring
revealed normal sinus rhythm with
frequent nonsustained ventricular
tachycardia. The patient was receiving a continuous intravenous infusion of lidocaine at 2 mg/min. His
heart rate was 70/min to 90/min in
normal sinus rhythm, and all other
vital signs were stable. The patient
reported continued chest pressure,
which was relieved with 1 sublingual nitroglycerin tablet.
On the basis of the earlier nuclear
imaging study, the cardiologist attributed the patients dysrhythmias and

other symptoms to ischemia; therefore, the patient was treated for acute
coronary syndrome. Lidocaine was
discontinued, and heparin and eptifibatide (Integrilin) intravenous
infusions were started. The patient
was prepared for and consented to
cardiac catheterization with possible percutaneous coronary intervention. Cardiac catheterization
revealed that the coronary arteries
had no obstructive disease; left ventricular ejection fraction was 65%
(normal 55%-75%).
During the next 24 hours of
continuous cardiac monitoring in
the CCU, nursing staff documented
numerous episodes of ventricular
tachycardia. The duration of the
tachycardia ranged from as few as
4 beats to many hours. The patient

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aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

V1

II

V5
40 Hz

25.0 mm/s

10.0 mm/mV

4 by 2.5 s + 3 rhythm leads

MAC5K 007A.2

12SLv235

Figure 2 Admission electrocardiogram of a patient with Belhassen ventricular tachycardia.

did not experience symptoms during


the dysrhythmic events. An electrophysiologist was consulted.
A 12-lead ECG recorded during
a sustained episode of ventricular
tachycardia revealed a wide-complex
tachycardia with a right bundle
branch block and a -155 axis deviation (Figure 2). The diagnosis was
Belhassen ventricular tachycardia.
The physician chose to treat the
patient with a -blocker because the
drug could provide effective treatment of the ventricular tachycardia
and prevent recurrences (rather than
verapamil, which would provide
treatment of the ventricular tachycardia but was less likely to prevent
recurrences). Metoprolol 5 mg intravenous push was administered, and
the ventricular tachycardia converted
to normal sinus rhythm (Figure 3).
The patient was then treated with
metoprolol 12.5 mg orally every 6
hours. After 24 hours, no further
ventricular tachycardia was observed.

An electrophysiologic study
was performed to evaluate the cardiac conduction system. The
patient also consented to ablation
of areas diagnosed as contributory
to the ventricular tachycardia. The
electrophysiologic study revealed
no evidence of conduction abnormality. Ventricular tachycardia
could not be induced despite multiple attempts. The patient was
offered the option of stopping
treatment with the -blocker and
repeating the electrophysiologic
procedure. He had not experienced
side effects with the -blocker and
chose not to have the electrophysiologic study repeated. He stated
that he preferred to continue taking the -blocker and that he
would stop taking the drug and
return for an electrophysiologic
study if his symptoms recurred.
The dose of metoprolol was
changed to 25 mg/d, and the
patient was discharged.

Nursing Care
The patient was admitted to
the CCU with a diagnosis of acute
coronary syndrome and possible
myocardial infarction. Morphine,
supplemental oxygen, and aspirin
had been administered previously
per protocol. In the emergency
department, the patient was given
intravenous nitroglycerin, and a
12-lead ECG was performed. Nursing care in the CCU continued to
include supplemental oxygen, intravenous nitroglycerin, and continuous
ECG monitoring for ST-segment
changes and dysrhythmias. The
nurses assigned to the patient
assessed respiratory rate and rhythm,
oxygen saturation via pulse oximetry, heart rate, blood pressure, pain,
and urine output every hour and as
needed. Blood pressure and heart
rate were within the reference ranges
at admission, so an intravenous
-blocker (metoprolol) was administered. Within the first 24 hours,

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aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

V1

II

V5
25 mm/s

10 mm/mV

40 Hz

005E

125SL 235

CID: 14

SID: 36374558 EID: 7124 EDT: 14:44 13-FEB-2008 ORDER:

Figure 3 Normal sinus rhythm with right bundle branch block in the same patient as in Figure 2 after treatment with intravenous
metoprolol.

an angiotensin-converting enzyme
inhibitor (captopril) was also
administered, with no complications. Breath sounds, neurological
status, heart sounds, peripheral
pulses, and skin color and temperature were assessed every 4 hours
and as needed per CCU protocol.
Serum levels of cardiac enzymes
(eg, troponin I, creatine kinase MB)
were determined every 6 hours until
the levels peaked.
Nursing considerations after cardiac catheterization included, but
were not limited to, assessing vital
signs, pedal pulses, and the groin
site every 15 minutes for the first
hour, every 30 minutes for the next
hour, and every hour for at least 2

To learn more about ventricular tachycardia,


read Nonsustained Ventricular Tachycardia
in the Elderly by Carey and Pelter in the
American Journal of Critical Care, 2006;15:
519-520. Available at www.ajcconline.org.

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hours thereafter. Checks of the groin


site included assessing the femoral
artery site used for the cardiac
catheterization to ensure that the site
was soft and without bleeding or
hematoma. The patient was maintained on bed rest for 4 hours. Staff
nurses were prepared to report to a
physician and to treat any abnormal
findings, including swelling, bleeding, loss of pedal pulse, and pain.8
Education on the importance of
keeping the leg that had been
accessed for the catheterization
straight for 3 to 6 hours after the
procedure and the head of the bed
elevation at 15 or less was explained.
The patient was taught how to
splint the site by holding slight
pressure over the groin if he felt the
need to cough, sneeze, or vomit.
When acute coronary syndrome
and myocardial infarction were ruled
out on the basis of the cardiac catheterization, the primary diagnosis

became dysrhythmia. Nursing care


then focused primarily on assessing
for any ECG changes, monitoring
for ventricular dysrhythmias,
assessing vital signs, and monitoring results of electrolyte assays
(especially potassium and magnesium levels). Electrolytes were
replaced as needed to maintain normal levels, and antidysrhythmics
were administered. The ECG was
monitored continuously for desired
effects as well as side effects.
The patient was taught about
the importance of adhering to his
medication schedule and follow-up
appointments with his physicians.
Signs and symptoms of the dysrhythmia (eg, lightheadedness, syncope, fatigue, palpitations) and
how to access the emergency medical system were reviewed. He was
taught how to take his pulse, and
he demonstrated that he could do
so accurately.

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Although the emphasis on education was directed


toward the patient, his wife was included to ensure that
members of his immediate support system knew about
the new changes in his regimen and specific signs and
symptoms.

Discussion
The patients history was typical for Belhassen ventricular tachycardia: male sex and beginning in his late
teens, intermittent dizziness and rare syncope. This
admission was the first time health care providers were
able to document a dysrhythmia. The patients hemodynamic status was stable, in either normal sinus rhythm
or ventricular tachycardia. The 12-lead ECG obtained
during ventricular tachycardia showed an irregular
wide-QRS-complex tachycardia with a right bundle
branch block and a -155 axis deviation (normal, 0 to
+90), making it difficult to differentiate between right
and left axis deviation. The diagnostic workup revealed
an anatomically normal heart.

The cardiologist ordered a 1-selective intravenous


-blocker (metoprolol) because of the patients history of
childhood asthma. Treatment with the drug converted
his cardiac dysrhythmia to normal sinus rhythm with a
right bundle branch block and a slight left axis deviation
(-4). The patient then was treated with metoprolol
orally. In the electrophysiology laboratory, the dysrhythmia could not be induced, so no ablation was performed.
Because he was tolerating the -blocker and had had no
further episodes of the ventricular tachycardia, the patient
elected to continue his current pharmacological treatment
and defer a repeat electrophysiologic study. The health
care team was supportive of the patients decision. Before
discharge, the patient and his family were taught about
medications, emergency management, and follow-up
care with physicians. CCN

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Acknowledgments
We acknowledge Elizabeth Allison for editorial assistance and Catherine
Berkemeyer for assistance with figures.

Financial Disclosures
None reported.

References
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679-682.
2. Chiu C, Sequeira IB. Diagnosis and treatment of idiopathic ventricular
tachycardia. AACN Clin Issues. 2004;15(3):449-461.
3. Stevenson WG, Delacretaz E. Radiofrequency catheter ablation of ventricular tachycardia. Heart. 2000;84(5):553-559.
4. Conover MB. Understanding Electrocardiography. 8th ed. St Louis, MO:
Mosby Elsevier; 2003.
5. Francis J, Venugopal K, Khadar SA, Sudhayakumar N, Gupta AK. Idiopathic fascicular ventricular tachycardia. Indian Pacing Electrophysiol J.
2004;4(3):98-103.
6. Gupta AK, Ganesh Kumar AV, Lokhanfwala YY, Vora AM, Maheshwari
A, Thakur RK. Primary radiofrequency ablation for incessant idiopathic
ventricular tachycardia. Pacing Clin Electrophysiol. 2002;25(11):15551560.
7. Topilski I, Glick A, Belhassen B. Idiopathic left ventricular tachycardia
with a right bundle branch block morphology and left axis deviation
(Belhassen type): results of radiofrequency ablation in 18 patients. Isr
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Belhassen Ventricular Tachycardia: A Case Study


Lauren Weaver, Michelle Curry, Linda Schakenbach and Kathleen Yakobitis
Crit Care Nurse 2010, 30:71-76. doi: 10.4037/ccn2010398
2010 American Association of Critical-Care Nurses
Published online http://www.cconline.org

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