<?xml version="1.0" encoding="UTF-8"?><article xml:lang="en" article-type="review-article"><front><journal-meta><journal-id journal-id-type="pmc-domain-id">360</journal-id><journal-id journal-id-type="pmc-domain">indiapace</journal-id><journal-title-group><journal-title>Indian Pacing and Electrophysiology Journal</journal-title><abbrev-journal-title>Indian Pacing Electrophysiol J</abbrev-journal-title></journal-title-group><publisher><publisher-name>Elsevier</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmcid">PMC2803604</article-id><article-id pub-id-type="pmcaid">2803604</article-id><article-id pub-id-type="pmcaiid">2803604</article-id><article-id pub-id-type="pmid">20084194</article-id><title-group><article-title>Accelerated Idioventricular Rhythm: History and Chronology of the Main Discoveries</article-title></title-group><contrib-group content-type="author"><contrib><name name-style="western"><surname>Riera</surname><given-names initials="ARP">Andres Ricardo Perez</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib><name name-style="western"><surname>Barros</surname><given-names initials="RB">Raimundo Barbosa</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib><name name-style="western"><surname>de Sousa</surname><given-names initials="FD">Francisco Daniel</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib><name name-style="western"><surname>Baranchuk</surname><given-names initials="A">Adrian</given-names></name><degrees>MD, FACC</degrees><xref ref-type="aff" rid="aff3">3</xref></contrib></contrib-group><aff id="aff1"><label>1</label>ABC Medical Faculty.  ABC Foundation. Santo Andre - Sao Paulo. Brazil</aff><aff id="aff2"><label>2</label>Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza-Ceara-Brazil</aff><aff id="aff3"><label>3</label>Kingston General Hospital, Queen's University, Kingston, Ontario, Canada</aff><author-notes><fn id="corresp1"><label>✉</label><p>Address for correspondence: Andres Ricardo Perez Riera MD, Sebastiao Afonso, 885CEP: 04417-000 - Jardim Miriam - Sao Paulo - Brazil. E-mail: <email>riera@uol.com.br</email></p></fn></author-notes><pub-date><day>7</day><month>1</month><year>2010</year></pub-date><volume>10</volume><issue>1</issue><fpage>40</fpage><page-range>40–48</page-range><pub-history><event event-type="pmc-release"><date><day>15</day><month>1</month><year>2010</year></date></event></pub-history><permissions><copyright-statement>Copyright: © 2009  Riera et al.</copyright-statement><license><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><self-uri xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="ipej100040-00.pdf" content-type="pmc-pdf"><?cloudpmc-path d0e7/2803604/c9649fb00fde/ipej100040-00.pdf?><?cloudpmc-bucket app?><?size 703992?></self-uri><abstract id="abstract1"><title>Abstract</title><p>Accelerated Idioventricular Rhythm (AIVR) is a ventricular rhythm consisting of three or more consecutive monomorphic beats, with gradual onset and gradual termination. It can rarely manifest in patients with completely normal hearts or with structural heart disease. It is usually seen during acute myocardial infarction reperfusion. This manuscript aims to review the history of the main discoveries that lead to the identification and comprehension of this fascinating arrhythmia.</p><sec id="kwd-group1" sec-type="kwd-group" disp-level="2"><p><bold>Keywords:</bold> Accelerated Idioventricular Rhythm, History and Chronology, Slow ventricular tachycardia</p></sec></abstract><custom-meta-group><custom-meta><meta-name>status</meta-name><meta-value>released</meta-value></custom-meta><custom-meta><meta-name>display-pdf</meta-name><meta-value>yes</meta-value></custom-meta><custom-meta><meta-name>is-olf</meta-name><meta-value>no</meta-value></custom-meta><custom-meta><meta-name>is-manuscript</meta-name><meta-value>no</meta-value></custom-meta><custom-meta><meta-name>is-preprint</meta-name><meta-value>no</meta-value></custom-meta><custom-meta><meta-name>is-journal-matter</meta-name><meta-value>no</meta-value></custom-meta><custom-meta><meta-name>is-scanned</meta-name><meta-value>no</meta-value></custom-meta><custom-meta><meta-name>is-retracted</meta-name><meta-value>no</meta-value></custom-meta></custom-meta-group></article-meta><notes notes-type="article-notes"><sec id="historyarticle-meta1" sec-type="history" disp-level="2"><p>Collection date 2010.</p></sec></notes></front><body><sec id="s1" disp-level="1"><title> Introduction - Definitions</title><p>The so called "Accelerated Idioventricular Rhythm" (AIVR) is a ventricular rhythm (originating from the His, the Purkinje system or the working contractile ventricular cells) consisting of three or more consecutive monomorphic beats, with gradual onset. Less commonly, AIVR is polymorphic. The discharge rate of the ectopic focus is similar to the sinus rate (isorhythmic) between 50 and 120 bpm. The ectopic focus manifests when the sinus rate slows down (below the ectopic focus) or when the ectopic focus accelerates above the intrinsic rate by 30-40 beats per minute. When both discharge rates (sinus and ectopic focus) are similar, isorhythmic dissociation, fusion and capture beats can be seen.</p><p>AIVR is usually a benign and well-tolerated arrhythmia. Most of the cases will require no treatment and in rare situations such as sustained or incessant AIVR or when AV dissociation induces syncope, the risk of sudden death is higher, and the arrhythmia should be treated.</p><p>Different terminology was used to describe AIVR: Non paroxysmal ventricular tachycardia (VT), isorhythmic slow VT, and the curious benevolent tachycardia.</p><p>Non paroxysmal VT is currently a non accepted definition given the fact that AIVR is usually a ventricular rhythm at rate slower than 100 bpm, thus not meeting criteria to be called tachycardia.</p></sec><sec id="s2" disp-level="1"><title>AIVR - Clinical Scenarios</title><p>Rarely, AIVR can be detected in the youth and, in this subgroup, is usually benign [<xref rid="R1" ref-type="bibr">1</xref>] and requires no specific treatment.</p><p>AIVR occurs infrequently in patients without demonstrable heart disease and, in this case, it has a good prognosis. When AIVR presents in individuals with no structural heart disease, the mechanism involved is usually an increased vagal tone and decreased sympathetic tone [<xref rid="R2" ref-type="bibr">2</xref>], as observed in athletes. The acceleration of an independent focus during exercise strongly suggests that this ectopic focus is under autonomic influence, a phenomenon also seen during central nervous system (CNS) stimulation in dogs [<xref rid="R3" ref-type="bibr">3</xref>]. A similar mechanism has also been described for pregnant women in the antenatal period [<xref rid="R4" ref-type="bibr">4</xref>].</p><p>AIVR is frequently observed during the reperfusion phase that follows an acute myocardial infarction (AMI) [<xref rid="R5" ref-type="bibr">5</xref>]. It remains controversial whether or not, AIVR implies complete reperfusion of the culprit lesion or only some degree of reperfusion.  AIVR has been also described associated with several drug intoxications such as halothane [<xref rid="R6" ref-type="bibr">6</xref>], aconitine [<xref rid="R7" ref-type="bibr">7</xref>], desflurane [<xref rid="R8" ref-type="bibr">8</xref>], cocaine [<xref rid="R9" ref-type="bibr">9</xref>], and digitalis [<xref rid="R10" ref-type="bibr">10</xref>-<xref rid="R12" ref-type="bibr">12</xref>]. Electrolyte imbalance has also been associated with AIVR in an experimental study [<xref rid="R13" ref-type="bibr">13</xref>]. There are also case reports published on the association of AIVR with the post-resuscitation period [<xref rid="R14" ref-type="bibr">14</xref>] (as an initial resolving rhythm), in chronic ischemic and non ischemic dilated cardiomyopathy [<xref rid="R15" ref-type="bibr">15</xref>], and less frequently in cardiomyopathies such as hypertrophic cardiomyopathy [<xref rid="R16" ref-type="bibr">16</xref>],  arrhythmogenic right ventricular dysplasia (ARVD) [17], and in newborn infants with different congenital heart diseases [<xref rid="R18" ref-type="bibr">18</xref>].</p><p>A typical example of AIVR in the setting of normal structural heart can be seen in <xref rid="F1" ref-type="fig">Figure 1</xref>. In <xref rid="F2" ref-type="fig">Figure 2</xref>, a case of AIVR in the context of a reperfused acute inferior MI can be seen.</p><fig id="F1" position="float"><?disp-level 2?><label>Figure 1</label><caption><p>This ECG belongs to a 23 year-old male patient, Caucasian, asymptomatic.  No cardiovascular history. He practiced physical activities regularly. He has been treated with azitromicine for an upper airway infection. Both panels show sinus rhythm alternating with AIVR at approximately 60 bpm. Note fusion beats (F).</p></caption><alternatives><graphic xmlns:xlink="http://www.w3.org/1999/xlink" content-type="image" xlink:href="ipej100040-01.jpg"><?cloudpmc-path blobs/d0e7/2803604/c01951a1c9dc/ipej100040-01.jpg?><?cloudpmc-bucket cdn?><?image-server-status LOAD_COMPLETED?><?original-height 967?><?original-width 700?><?scaled-height 967?><?scaled-width 700?></graphic><graphic xmlns:xlink="http://www.w3.org/1999/xlink" content-type="thumb" xlink:href="ipej100040-01.gif"><?cloudpmc-path blobs/d0e7/2803604/821c0b058309/ipej100040-01.gif?><?cloudpmc-bucket cdn?></graphic></alternatives></fig><fig id="F2" position="float"><?disp-level 2?><label>Figure 2</label><caption><p>This ECG belongs to a 67 year-old woman, presenting to the ER with an acute inferior MI (superior panel). During the administration of thrombolytics, AIVR can be seen (inferior panel) at rate of 88 bpm. AIVR alternates with sinus captures (C) and fusion beats (F).</p></caption><alternatives><graphic xmlns:xlink="http://www.w3.org/1999/xlink" content-type="image" xlink:href="ipej100040-02.jpg"><?cloudpmc-path blobs/d0e7/2803604/49e70bec94d7/ipej100040-02.jpg?><?cloudpmc-bucket cdn?><?image-server-status LOAD_COMPLETED?><?original-height 939?><?original-width 700?><?scaled-height 939?><?scaled-width 700?></graphic><graphic xmlns:xlink="http://www.w3.org/1999/xlink" content-type="thumb" xlink:href="ipej100040-02.gif"><?cloudpmc-path blobs/d0e7/2803604/53bd504ee85e/ipej100040-02.gif?><?cloudpmc-bucket cdn?></graphic></alternatives></fig></sec><sec id="s3" disp-level="1"><title>Mechanisms</title><p>The main electrophysiological mechanism involved in AIVR is an abnormal calcium-dependent automatism (ectopic automaticity) that affect phase 4 of action potential (diastolic depolarization) [<xref rid="R19" ref-type="bibr">19</xref>]. When AIVR is associated with digitalis intoxication, the main arrhythmogenic mechanism involved is trigger activity [<xref rid="R20" ref-type="bibr">20</xref>].</p><p>This manuscript aims to be a chronological historical review on the main findings that contributed to the understanding of this fascinating arrhythmia.</p></sec><sec id="s4" disp-level="1"><title>Chronology of discoveries</title><sec id="s4a" disp-level="2"><title>1925:</title><p>Sir Thomas Lewis (December 26th, 1881, Cardiff, Gales - March 17th 1945) a pioneer of the British cardiology showed the first ECG trace of AIVR case in his book entitled "Mechanism and graphic registration of the heartbeat"  [<xref rid="R21" ref-type="bibr">21</xref>], dedicated to Willem Einthoven. He failed to identify AIVR as an independent arrhythmia. This book is considered the first book on Electrocardiography, as highlighted by Prof. Schapiro [<xref rid="R22" ref-type="bibr">22</xref>] a well-recognized historian in electrocardiology and arrhythmias. Several years prior to the publication of his book, Sir Lewis reported in The Lancet (1909) an interesting article about the mechanisms of VT without mentioning its slower forms [<xref rid="R23" ref-type="bibr">23</xref>].</p></sec><sec id="s4b" disp-level="2"><title>1950:</title><p>Harris [<xref rid="R24" ref-type="bibr">24</xref>] was the first one to identify AIVR associated with ischemia and reperfusion in an experimental study. He observed this rhythm after clamping the right coronary artery. He identified the origin of this rhythm in the ventricles and described a similar heart rate than the sinus discharge. He also mentioned that this rhythm may overrate the sinus rate but also could be inhibited by increasing the sinus discharge.</p></sec><sec id="s4c" disp-level="2"><title>1966:</title><p>Mariot and Menendez [<xref rid="R25" ref-type="bibr">25</xref>] have introduced the currently accepted terminology: AIVR.</p></sec><sec id="s4d" disp-level="2"><title>1967:</title><p>Dessertene [<xref rid="R26" ref-type="bibr">26</xref>] described for the first time the term "slow ventricular tachycardia"</p></sec><sec id="s4e" disp-level="2"><title>1969:</title><p>Agustín Castellanos Jr [<xref rid="R19" ref-type="bibr">19</xref>] used the term "slow ventricular tachycardia" during an acute MI to describe a case of AIVR. Additionally, the authors explained the underlying electrophysiological mechanisms of AIVR.</p></sec><sec id="s4f" disp-level="2"><title>1973:</title><p>Rothfeld et al [<xref rid="R27" ref-type="bibr">27</xref>] showed for the first time the coexistence of paroxysmal ventricular tachycardia and "idioventricular rhythm" during an acute MI.</p></sec><sec id="s4g" disp-level="2"><title>1974:</title><p>Rothfeld and Zucker [<xref rid="R28" ref-type="bibr">28</xref>], were the first ones to describe the polymorphic form of AIVR. They named it "Multiform accelerated idioventricular rhythm". Sclarowski, 4 years later (1978), published 2 cases with polymorphic presentation in the Journal of Electrocardiology [<xref rid="R29" ref-type="bibr">29</xref>].</p></sec><sec id="s4h" disp-level="2"><title>1975:</title><p>Agustín Castellanos Jr et al [<xref rid="R10" ref-type="bibr">10</xref>] reported digitalis-induced AIVR for the first time in the literature.  Scheinman et al [<xref rid="R30" ref-type="bibr">30</xref>] reported the efficacy of atropine to suppress AIVR during the acute MI. Basy and Scheinman [<xref rid="R31" ref-type="bibr">31</xref>] reported the sustained form of AIVR in an elderly patient suffering an inferior MI. The authors successfully treated the patient with IV Procainamide. The same year, Castellanos et al [<xref rid="R32" ref-type="bibr">32</xref>] reported an AIVR from two different foci. They named it "double ectopic accelerated ventricular rhythm".</p></sec><sec id="s4i" disp-level="2"><title>1976:</title><p>Hasin and Rogel [<xref rid="R33" ref-type="bibr">33</xref>] presented the currently accepted mechanism involved in AIVR. They postulated the involvement of the phase 4 slope of the action potential (ectopic automaticity) for the unstable form of AIVR that is frequently observed in  acute MI. The same year, Doshchitsin and Merkulova from Russia [<xref rid="R34" ref-type="bibr">34</xref>], used the terminology "non-paroxysmal ventricular tachycardia".</p></sec><sec id="s4j" disp-level="2"><title>1980:</title><p>Delise et al [<xref rid="R15" ref-type="bibr">15</xref>] reported the first case of AIVR associated with hypertrophic cardiomyopathy.</p></sec><sec id="s4k" disp-level="2"><title>1981:</title><p>Bernard et al [<xref rid="R1" ref-type="bibr">1</xref>], described AIVR in a pediatric patient. They highlighted the usual benign course of this arrhythmia in this population.</p></sec><sec id="s4l" disp-level="2"><title>1983:</title><p>Sclarovsky et al [<xref rid="R35" ref-type="bibr">35</xref>], showed a partial benefit of eliminating AIVR by treating a patient with Verapamil. The same year, Golderberg et al [<xref rid="R36" ref-type="bibr">36</xref>], reported that the presence of AIVR during the acute phase of a MI treated with thrombolytic therapy, rather than a malignant sign, implies reperfusion of the culprit lesion. The sensitivity is low but the specificity is high (&gt; 80%). Jonsson et al [<xref rid="R9" ref-type="bibr">9</xref>] described the association of AIVR with the use of cocaine.</p></sec><sec id="s4m" disp-level="2"><title>1987:</title><p>Chiale et al [<xref rid="R37" ref-type="bibr">37</xref>], reported a case of slow automaticity in a young patient with no structural heart disease. </p></sec><sec id="s4n" disp-level="2"><title>1988:</title><p>Martini et al [<xref rid="R16" ref-type="bibr">16</xref>] described the first case of AIVR originating in the infundibular region of the right ventricle in a patient with a concealed form of arrhythmogenic right ventricular dysplasia (ARVD).</p></sec><sec id="s4o" disp-level="2"><title>1991:</title><p>Tatu-Chitoiu [<xref rid="R38" ref-type="bibr">38</xref>], used the term "Non-paroxysmal ventricular tachycardia with isorhythmic atrioventricular dissociation" to described AIVR.</p></sec><sec id="s4p" disp-level="2"><title>1993:</title><p>Nakawa et al [<xref rid="R18" ref-type="bibr">18</xref>], showed that AIVR had no impact in long-term prognosis in a large population of pediatric patients with congenital heart disease. The same year, Martinez-Lopez JI et al [<xref rid="R39" ref-type="bibr">39</xref>], created the term "benevolent rhythm" to describe AIVR. This term has not convinced the cardiology community and currently is not been used.</p></sec><sec id="s4q" disp-level="2"><title>2000:</title><p>Grimm et al [<xref rid="R14" ref-type="bibr">14</xref>] followed up a series of patients with AIVR with idiopathic dilated cardiomyopathy. The presence of the arrhythmia did not impact on long-term prognosis.</p></sec><sec id="s4r" disp-level="2"><title>2002:</title><p>Marret et al [<xref rid="R8" ref-type="bibr">8</xref>] reported a case of AIVR associated with desflurane intoxication.</p></sec><sec id="s4s" disp-level="2"><title>2004:</title><p>Dulac et al [<xref rid="R4" ref-type="bibr">4</xref>], reported the first case of AIVR in a pregnant woman in the antenatal period.</p></sec><sec id="s4t" disp-level="2"><title>2005:</title><p>Bonnemeier et al [<xref rid="R2" ref-type="bibr">2</xref>], determined that AIVR is not a specific marker of reperfusion during an acute MI treated with thrombolytics. The presence of AIVR could not distinguish between complete or incomplete reperfusion. They established a connection between AIVR and autonomic nervous system imbalance, AIVR being more frequently associated with increased parasympathetic tone and decreased sympathetic tone. The authors confirmed that the presence of AIVR did not affect the short or long-term prognosis.</p></sec><sec id="s4u" disp-level="2"><title>2007:</title><p>Tsai et al [<xref rid="R13" ref-type="bibr">13</xref>] reported the first case of AIVR in a post-resuscitated patient.  The same year, Nasir et al [<xref rid="R40" ref-type="bibr">40</xref>], reported cases of AIVR in elite athletes. Again, the authors related the presence of the arrhythmia with autonomic dysfunction (hypervagotonia). Fuyita et al [<xref rid="R7" ref-type="bibr">7</xref>] reported a case of AIVR associated with intoxication with acotinine.</p></sec><sec id="s4v" disp-level="2"><title>2008:</title><p>Hsu et al [<xref rid="R41" ref-type="bibr">41</xref>], reported the first case of AIVR associated with Buerger disease (also known as thromboangiitis obliterans) and MI. In the same year, Chhabra et al [<xref rid="R6" ref-type="bibr">6</xref>] reported a case of AIVR observed during inhalational induction with halothane in a child with congenital cataract. Osmancik et al  [<xref rid="R42" ref-type="bibr">42</xref>], confirmed that the value of AIVR alone as a criteria for reperfusion is low, but in addition to normalization of the ST-segment, the probability of successful reperfusion is higher.</p></sec></sec><sec id="s5" disp-level="1"><title>Conclusions</title><p>This intriguing arrhythmia could manifest in several different clinical scenarios. There are benign forms in subjects with no structural heart disease in which case, it usually requires no intervention, but sometimes it can present as a more severe arrhythmia, requiring treatment. Since its initial identification by Harris, major advances have been done in the understanding on the underlying mechanisms involved in the genesis of this arrhythmia. Abnormal calcium-dependent automatism that affects the phase 4 slope of the action potential (ectopic automaticity) has been identified as the main electrophysiological mechanism involved in AIVR. Autonomic imbalance has also been identified as a trigger of this abnormal rhythm. More recent reports showed that the presence of AIVR does not constitute a specific marker of complete reperfusion during the acute phase of a myocardial infarction, but it could indicate that the responsible vessel is open.  In this context, AIVR usually does not require specific treatment.</p></sec><sec id="ref-list1" sec-type="ref-list" disp-level="1"><title>References</title><sec id="ref-list1_sec2" disp-level="2"><ref-list><ref id="R1"><mixed-citation><named-content content-type="citation-string">Bernard Y, et al.  Accelerated idioventricular rhythm in children. Apropos of a case. 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