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Abstract
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CLEAR FILTERS
Sailing through an electrical storm without losing synchrony
Session:
Casos Clínicos desafiantes 1
Speaker:
Rafael Silva Teixeira
Congress:
CPC 2023
Topic:
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Theme:
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Subtheme:
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Session Type:
Speaker´s Corner
FP Number:
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Authors:
Rafael Silva Teixeira; Fabio Sousa Nunes; João Almeida; Mariana Brandão; Diogo Ferreira; Olga Sousa; Pedro Teixeira; Marta Ponte; Adelaide Dias; Paulo Fonseca; Helena Gonçalves; Marco Oliveira; Daniel Caeiro; João Primo; Ricardo Fontes Carvalho
Abstract
<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="font-size:13.5pt"><span style="font-family:"Avenir Book""><span style="color:black">A 68-year-old man with a previous history of elitism, smoking, obesity, and arterial hypertension, was admitted to the emergency department because of respiratory distress and non-sustained extreme tachycardia (230 bpm) but no other signs of hemodynamic instability. The patient described ongoing palpitations for the last 24 hours and denied chest pain. EKG showed regular monomorphic wide complex tachycardia at 210 bpm, with an upper directed electrical axis and right bundle block pattern, compatible with ventricular tachycardia (VT). QTc prolongation and ionic disturbances were ruled out. Endovenous (EV) amiodarone, lidocaine, and esmolol were started, and the patient was admitted to the cardiac intensive care unit (ICU). Because of repeated VT episodes, a temporary EV pacemaker (PM) was positioned for overdrive pacing. Few hours after admission to ICU, VT became sustained, and hemodynamic instability ensued. Initial attempts of overdrive pacing, sedation and electrical cardioversion failed, so the patient was intubated and placed under circulatory support with venoarterial-ECMO. Emergent coronary angiography revealed chronic long occlusion of the right coronary artery partially recanalized in the middle segment. Transthoracic echocardiogram (TTE) revealed akinesia with hyperechogenicity of the left ventricle (LV) inferior wall and severe depression of the LV systolic function. Frequent VT episodes, despite pharmacologic measures, prompted percutaneous ablation of the left stellate ganglion on day 6, which slowed the ventricular rhythm. This allowed overdrive suppression of ventricular ectopy by setting the PM discharge rate to 100 bpm and ECMO explantation on day 9. However, loss of atrioventricular (AV) and biventricular (BiV) synchrony had a deleterious effect on hemodynamics, preventing tapering pressors. On day 10, PM was repositioned into the right atrium and later replaced by an active-fixation lead which preserved AV and BiV synchrony and increased cardiac output. On day 16, the patient removed the PM and underwent an electrophysiologic study with substrate-guided ablation of the LV inferior wall. He was extubated on day 18, and no significant arrhythmic events were recorded thereafter. ICU stay was prolonged due to thrombotic occlusion of the common femoral artery requiring surgical thrombectomy, surgical site infection, and pneumonia. Finally, on day 39, an implanted cardioverter defibrillator was implanted, and the patient was discharged to home.</span></span></span></span></span></span></p>
Slides
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