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CLEAR FILTERS
Life-threatening arrhythmia – think twice!
Session:
Sessão Speaker’s Corner - Casos Clínicos desafiantes… em Arritmologia
Speaker:
Paulo Medeiros
Congress:
CPC 2022
Topic:
C. Arrhythmias and Device Therapy
Theme:
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Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Paulo Medeiros; Cátia Oliveira; Carla Pires; Rui Flores; Fernando Mané; Rodrigo Silva; Inês Conde; Carina Arantes; Sónia Magalhães; Adília Rebelo; Sérgia Rocha
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">This is the case of a 72-year-old man with background of arterial hypertension and no relevant familial history. The patient presented to the emergency department of the first hospital after an episode of transient loss of consciousness when he was climbing a staircase. The patient and his wife described spontaneous recovery in <2 minutes. On initial evaluation, the patient had no further complaints besides headache from head trauma. Physical examination was unremarkable. </span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">ECG revealed sinus rhythm, HR 70/min, no relevant anomalies including ST-T changes. Blood chemistry was unremarkable. Computed tomography pulmonary angiogram ruled out pulmonary embolism. While he was waiting on the observation room, the patient experienced another episode of syncope. ECG monitoring revealed ventricular fibrillation. In-hospital emergency was activated, and the patient was promptly started on cardiopulmonary resuscitation. Spontaneous circulation was achieved after 2 shocks. Transthoracic echocardiogram (TTE) revealed preserved systolic function of both left and right ventricles, mild left atrium dilatation and moderate concentric left ventricle (LV) hypertrophy. He was referred to coronary angiography. The study revealed occlusion of the distal segment of the right coronary artery (RCA). Percutaneous coronary intervention of the RCA lesion was successfully performed. </span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">During the following day, a new episode of cardiac arrest was observed. ECG tracing revealed a polymorphic ventricular tachycardia initiated by a “R on T” phenomenon. The patient was defibrillated again and recovered spontaneous circulation. He was then transferred to our center. TTE reassessment did not find <em>de novo</em> changes. Cardiac magnetic resonance revealed hypokinesia of the mid and basal portions of the inferior LV wall with late gadolinium enhancement on this region (75% transmurality), with no signs of myocardial edema (compatible with an inferior infarction scar).</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">As we interpreted this scenario as a primary life-threatening rhythmic event (and not scar-related), we decided to implant a dual-chamber implantable cardioverter defibrillator (ICD). After impregnation with amiodarone, the patient experienced no further ventricular arrhythmias and was successfully discharged. On current follow-up, the patient remains asymptomatic without the need for ICD-delivered therapies.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">Although polymorphic VT and ventricular fibrillation are often related to acute coronary syndromes, other etiologies should be considered. VTs originating from myocardial scars are usually monomorphic. Secondary prevention of sudden cardiac death with an ICD is recommended in cases of life-threatening ventricular arrhythmias with no reversible cause. </span></span></span></p>
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