SPC365

“A stitch in time…” - A successful case of refractory VT

Session: Prémio Melhor Caso Clínico
Speaker: Rita Amador

Congress: CPC 2023
Topic: P. Other
Theme: 37. Miscellanea
Subtheme: ---
Session Type: Sessão de Prémios
FP Number: ---
Authors: Rita Catarina Ramos Amador; António Tralhão; Maria Rita Lima; Daniel Gomes; Catarina Brízido; Christopher Strong; Daniel Matos; Pedro Galvão Santos; Pedro Carmo; Professor Dr. Pedro Adragão
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-family:&quot;Times New Roman&quot;,serif">Background:</span></strong></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-family:&quot;Times New Roman&quot;,serif">Ventricular tachycardia (VT) is a known complication of a variety of cardiomyopathies, often requiring radiofrequency catheter ablation (RFCA). Despite recent advances, refractory VT remains a cardiologic emergency with a high mortality rate. </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-family:&quot;Times New Roman&quot;,serif">Case presentation:</span></strong></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-family:&quot;Times New Roman&quot;,serif">A 62-year-old male with idiopathic dilated cardiomyopathy presented with palpitations and fatigue. CRT-D interrogation showed multiple anti-tachycardia pacing therapies for VT at 160 bpm. Laboratory work-up excluded reversible causes. He was admitted and underwent substrate-guided epicardial catheter ablation.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-family:&quot;Times New Roman&quot;,serif">At day 4, he began a fast VT storm (180 bpm), refractory to device therapies, IV amiodarone and lidocaine. Due to the haemodynamic instability, he was transferred to the CICU, where he was sedated and intubated, aiming to adrenergic drive suppression. He quickly evolved into pulseless VT. CPR was immediately initiated and the decision was made to move on to eCPR at the bedside. Total low-flow time was 28 minutes with end-tidal CO<sub>2 </sub>persistently above 15 mmHg. Maximum lactate levels were 2.3 mmol/L. Post VA-ECMO cannulation echocardiogram showed severe LV disfunction with no LV ejection and an intra-aortic balloon pump was implanted for LV venting. </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-family:&quot;Times New Roman&quot;,serif">The patient remained in the cardiac ICU under ECMO support, continuous amiodarone and lidocaine infusions, allowing gradual cardiac function improvement. As VT recurred 5 days after ECMO implantation a re-do catheter ablation while under mechanical circulatory support and temporary non-fractionated heparin suspension was attempted. Induction of VT with a 340 ms cycle and an RBBB-like morphology was achieved and activation mapping showed critical isthmus in the inferolateral region. During RF applications the cycle length increased to 390 ms, maintaining the morphology. Mapping of the second VT identified the critical isthmus at a slightly superior and lateral location. VT was interrupted during RF application. </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-family:&quot;Times New Roman&quot;,serif">The likelihood of a successful VT ablation and the LV function recovery allowed the patient to be weaned off mechanical circulatory support after 2 days of ECMO-run, percutaneously decannulated, extubated and later transferred to the cardiology ward. </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-family:&quot;Times New Roman&quot;,serif">No neurological sequelae remained after the patient regained conscience. During a 4-month follow-up period there was no recurrence of VT under beta-blockade and amiodarone. </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-family:&quot;Times New Roman&quot;,serif">Conclusion:</span></strong></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-family:&quot;Times New Roman&quot;,serif">Refractory VT storm may be a deadly consequence of cardiac disease. A timely decision to start eCPR in a patient who had previously demonstrated a low likelihood of successful cardioversion, together with highly efficient chest compressions by a trained team, were fundamental to ensure the patient&rsquo;s favourable neurological outcome.&nbsp; Furthermore, having the patient under VA-ECMO allowed the electrophysiology team to induce and safely map the VT circuit, thus setting the ground for an effective catheter ablation. </span></span></span></p>