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A3443 - Refractory Sustained Ventricular Tachycardia (VT) Storm in the Setting of Left Ventricular Cardiomyopathy, Right Ventricular Outflow Tract Tachycardia and Wolf Parkinson White Syndrome
Author Block: A. Martin, S. Reddy, J. S. Alpert; Internal medicine, University of Arizona- Banner University medical center, Tucson, AZ, United States.
Ventricular tachycardia caused by structural heart disease in combination with reduced ejection fraction can lead to sudden cardiac arrest. This case is unique in the unusually complicated medical history and as a successful learning case. The patient decompensated in a matter of hours with critical care needs for cardiac and pulmonary support devices. A 54 year old man with a past medical history of Wolf-Parkinson-White syndrome, atrial fibrillation, ventricular tachycardia status post atrial and ventricular remote ablations and nonischemic left ventricular cardiomyopathy with reduced ejection fraction of 28% status post dual chamber implantable cardioverter defibrillator (ICD) presented for chest discomfort secondary to ICD discharge. The patient was originally scheduled for a ventricular ablation with the electrophysiology service. At the time of admission the patient was hemodynamically stable with an appropriately functioning ICD. Medication compliance was excellent consisting of mexilitene and sotalol. On admission, an electrophysiology consult recommended amiodarone infusion. Cardiac MRI showed an extensive scar on the anterior and inferior septum with dyskinesia. The day following admission the patient developed VT storm refractory to multiple attempts at anti-tachycardia pacing via the ICD and ICD initiated defibrillation. As a result the patient was intubated and sedated. Prolonged, unremitting refractory monomorphic ventricular tachycardia with escalating hemodynamic instability required percutaneous left ventricular heart assist device, impella cardiac support via an axillary approach for stabilization. Catheterization was negative for coronary disease. Electrophysiology studies: An electroanatomical map of the right ventricle was created using CARTO and the Pentaray catheter. This revealed a region of bipolar voltage attenuation and abnormal electrogram characteristics (fractionated, split, and late electrograms) present at the basal aspect of the right ventricle. The substrate appeared to spare the tricuspid-pulmonic isthmus. Ablation was performed on the substrate induced by programmed stimulation. The electrophysiology cardiologist suspected this patient manifested scar mediated reentrant VT. Post-ablation and external cardioversion there were no further episodes of ventricular tachycardia. As a result of cardiogenic shock and hypotension during tachyarrhythmia the patient developed acute kidney injury with anuria likely related to hypoperfusion of the renal vasculature as well as contrast-induced nephropathy. At the time of this abstract, the patient has been successfully extubated with explantation of the impella device. Cardiac biopsy of the septal myocardial scarring was attempted but failed. A spiculated mass in the right upper lobe of the lung and myocardial scarring likely inciting the arrhythmogenic events may be the result of sarcoidosis. Further evaluation is underway.