Massive inferior wall aneurysm presenting with ventricular tachycardia and refractory cardiomyopathy requiring multiple interventions:A case report

BACKGROUND Inferior wall left ventricular aneurysms are rare,they develop after transmural myocardial infarction(MI)and may be associated with poorer prognosis.We present a unique case of a large aneurysm of the inferior wall complicated by ventricular tachycardia(VT)and requiring surgical resection and mitral valve replacement.CASE SUMMARY A 59-year-old male was admitted for VT one month after he had a delayed presentation for an inferior ST-segment elevation MI and was discovered to have a large true inferior wall aneurysm on echocardiography and confirmed on coronary computed tomography(CT)angiography.Due to the sustained VT,concern for aneurysm expansion,and persistent heart failure symptoms,the patient was referred for surgical resection of the aneurysm with patch repair,mitral valve replacement,and automated implantable cardioverter defibrillator insertion with significant improvement in functional and clinical status.CONCLUSION Inferior wall aneurysms are rare and require close monitoring to identify electrical or contractile sequelae.Coronary CT angiography can outline anatomic details and guide surgical intervention to ameliorate life-threatening complications and improve performance status.

Peripartum Cardiomyopathy Complicated by Ventricular Tachycardia during Labor: A Case Report and Literature Review

Background: Peripartum cardiomyopathy (PPCM) is a rare disease that typically affects young, healthy women. Because PPCM is associated with significant mortality, timely diagnosis and management are essential. Ventricular tachycardia (VT) is a major complication and contributor to sudden death. Available data on VT in patients with PPCM are limited. Aim: This case report demonstrates the clinical presentation, antenatal care, and management of labor and delivery in a patient with PPCM complicated by VT. Case report: 36-year old patient G4P3 presents at 27 weeks gestation to the emergency department complaining of chest tightness, palpitations, and profuse sweating. Peripartum cardiomyopathy was diagnosed after her last pregnancy a few years prior. Ventricular tachycardia was diagnosed at this visit and treated successfully. The remainder of the pregnancy was uneventful until she had another episode of ventricular tachycardia during labor. Treatment using antiarrhythmics (diltiazem, amiodarone, adenosine) highlights the importance of prompt intervention and the need for a range of therapeutic options. Results: This case demonstrated successful VT management during pregnancy and labor, emphasizing multidisciplinary collaboration, influencing maternal and fetal outcomes positively, providing insights into optimal care strategies. Conclusion: Peripartum cardiomyopathy complicated by ventricular tachycardia is a life-threatening combination. This case highlights the importance of timely diagnosis and management with combined care between cardiologists, maternal fetal medicine specialists and anesthesiologists to prevent morbidities and sudden maternal death.

Ventricular tachycardia ablation and substrate modification in ICD patients with electrical storm

The electrical storm （ES） is defined as a state of electrical instability with three or more sustained ventricular arrhythmias （VAs） occurring within twenty-four hours, which needs intravenous antiarrhythmic medications and frequent defibrillation. Recently, radiofrequency catheter ablation evolved as a sole therapy to terminate ES in patients with ICD, and the survival has been reported to be improved with successful ablation during follow-up. In this review, we briefly summarize substrate mapping and substrate ablation strategy in patients with ES, and discuss the reason of recurrence after ablation.

Management of ventricular tachycardia storm in patients with structural heart disease

Electrical storm(ES) is a medical emergency characterized by repetitive episodes of sustained ventriculararrhythmias(VAs) in a limited amount of time(at least 3 within a 24-h period) leading to repeated appropriate implantable cardioverter defibrillator therapies. The occurrence of ES represents a major turning point in the natural history of patients with structural heart disease being associated with poor short-and longterm survival particularly in those with compromised left ventricular ejection fraction(LVEF) that can develop hemodynamic decompensation and multi-organ failure. Management of ES is challenging with limited available evidence coming from small retrospective series and a substantial lack of randomized-controlled trials. In general, a multidisciplinary approach including medical therapies such as anti-arrhythmic drugs, sedation, as well as interventional approaches like catheter ablation, may be required. Accurate patient risk stratification at admission for ES is pivotal and should take into account hemodynamic tolerability of VAs as well as comorbidities like low LVEF, advanced NYHA class and chronic pulmonary disease. In high risk patients, prophylactic mechanical circulatory support with left ventricular assistance devices or extracorporeal membrane oxygenation should be considered as bridge to ablation and recovery. In the present manuscript we review the available strategies for management of ES and the evidence supporting them.

Trigger elimination of polymorphic ventricular tachycardia and ventricular fibrillation by catheter ablation:trigger and substrate modification

Ventricular fibrillation （VF） is a malignant arrhythmia, usually initiated by a ventricular premature contraction （VPC） during the vulnerable period of cardiac repolarization. Ablation therapy for VF has been described and increasingly reported. Targets for VF triggers are VPCs preceded by Purkinje potentials or from the right ventricular outflow tract （RVOT） in structurally normal hearts, and VPC triggers preceded by Purkinje potentials in ischemic cardiomyopathy. During the session, mapping should be focused on the earliest activation and determining the earliest potential is the key to a successful ablation. However, suppression of VF can be achieved by not only the elimination of triggering VPCs, but also by substrate modification of possible reentry circuits in the Purkinje network, or between the PA and RVOT. The most important issue before the ablation session is the recording of the 12-lead ECG of the triggering event, which can prove invaluable in regionalizing the origin of the triggering VPC for more detailed mapping. In cases where the VPC is not spontaneous or inducible, ablation may be performed by pace mapping. Further studies are needed to evaluate the precise mechanisms of this arrhythmia.

Phrenic nerve displacement by intrapericardial balloon inflation during epicardial ablation of ventricular tachycardia: Four case reports

BACKGROUND Phrenic nerve(PN)injury is one of the recognized possible complications following epicardial ablation of ventricular tachycardia(VT).High-output pacing is a widely used maneuver to establish a relationship between the PN and the ablation catheter tip.An absence of PN capture is usually considered an indication that it is safe to ablate,and that successful ablation may be performed at adjacent sites.However,PN capture may impact the procedural outcome.Only a few cases have been reported in the literature that avoid PN injury by using different techniques.CASE SUMMARY Three patients with a previous history of myocarditis and one patient with ischemic cardiomyopathy underwent epicardial ablation for drug-refractory VT.Before the procedure,transthoracic echocardiogram,coronary angiogram,and cardiac magnetic resonance imaging were performed on all patients.Under general anesthesia,endo/epicardial three-dimensional anatomical and substrate maps of the left ventricle were accomplished.Before radiofrequency delivery,the course of the PN was identified by provoking diaphragmatic stimulation with high-output pacing from the distal electrode of the ablation catheter.In every case,a scar region with late potentials was mapped along the PN course.After obtaining another epicardial access,a second introducer sheath was placed,and a vascular balloon catheter was inserted into the epicardial space and inflated with saline solution to separate the PN from the epicardium.Once the absence of PN capture had been proven,radiofrequency was applied to aim for complete late potential elimination and avoid VT induction.CONCLUSION PN injury can occur as one of the complications following epicardial VT ablation procedures,and may prevent successful ablation of these arrhythmias.PN displacement by using large balloon catheters into the epicardial space seems to be feasible and reproducible,avoid procedure-related morbidity,and improve ablation success when performed in selected centers and by experienced operators.

Optimal programming management of ventricular tachycardia storm in ICD patients

Ventricular tachycardia storm （VTS） is defined as a life-threatening syndrome of three or more separate episodes of ventricular tachycardia （VT） leading to implantable cardioverter defibrillator （ICD） therapy within 24 hours. Patients with VTS have poor outcomes and require immediate medical attention. ICD shocks have been shown to be associated with increased mortality in several studies. Optimal programming in minimization of ICD shocks may decrease mortality. Large controlled trials showed that long detection time and high heart rate detection threshold reduced ICD shock burden without an increase in syncope or death. As a fundamental therapy of ICD, anti- tachycardia pacing （ATP） can terminate most slow VT with a low risk of acceleration. For fast VT, burst pacing is more effective and less likely to result in acceleration than ramp pacing. One algorithm of optimal programming management during a VTS is presented in the review.

Fast rate （≥ 250 beats/min） right ventricular burst stimulation is useful for ventricular tachycardia induction in arrhythmogenic right ventricular cardiomyopathy

Background One of the major challenges in arrhythmogenic right ventricular cardiomyopathy （ARVC） ablation is ventricular tachy-cardia （VT） non-inducibility. The study aimed to assess whether fast rate （≥ 250 beats/min） right ventricular burst stimulation was useful for VT induction in patients with ARVC.Methods Ninety-one consecutive ARVC patients with clinical sustained VT that underwent electro-physiological study were enrolled. The stimulation protocol was implemented at both right ventricular apex and outflow tract as follows： Step A, up to double extra-stimuli; Step B, incremental stimulation with low rate （＆lt; 250 beats/min）; Step C, burst stimulation with fast rate （≥ 250 beats/min）; Step D, repeated all steps above with intravenous infusion of isoproterenol.Results A total of 76 patients had inducible VT （83.5%）, among which 49 were induced by Step C, 15 were induced by Step B, 8 and 4 by Step A and D, respectively. Clinical VTs were induced in 60 patients （65.9%）. Only two spontaneously ceased ventricular fibrillations were induced by Step C. Multivariate analysis showed that a narrower baseline QRS duration under sinus rhythm was independently associated with VT non-inducibility （OR： 1.1; 95% CI： 1.0-1.1;P = 0.019）.ConclusionFast rate （≥ 250 beats/min） right ventricular burst stimulation provides a useful supplemental method for VT induction in ARVC patients.

Normalization of plasma growth hormone alleviated malignant ventricular tachycardia in acromegaly

Acromegaly is an insidious endocrine disease character- ized by chronic elevation of growth hormone （GH） and insulin-like growth factor-1 （IGF-1）.Ell Persistent excess se- cretion of GH and IGF-1 damages both cardiac structure and function, leading to acromegalic cardiomyopathy, which is one of the most common causes of increased mortality in acromegaly and can result in an average of 10-year reduction in life expectancy.I2＇31 In patients with acromegaly, approximately 3% have been reported having a unique cardiomyopathy characterized by biventricular hypertrophy, myocardial necrosis, lymphocytic infiltration, interstitialfibrosis.

Radiofrequency catheter ablation of ventricular tachycardia in a patient with dermatomyositis

A 51-year old male who presented at our hospital for recurrent palpitation for several months was diagnosed dermatomyositis ten years ago and had interstitial lung disease since two years ago. Recently, he was admitted for atypical hepatitis, and received maintenance treatment of oral corticosteroids.

Polymorphic ventricular tachycardia during phase Ⅱ cardiac rehabilitation in a patient with heart failure: a case report

A 67-year-old man with a history of a prior cardiac arrest with ventricular fibrillation(VF)due to myocardial infarction underwent phase I(inpatient)and II(outpatient)cardiac rehabilitation(CR)exercise training.On the 33th CR session,15 min after the start of exercise training,the patient had syncope with evidence of a polymorphic and wide QRS complex tachycardia on electrocardiogram(ECG)monitoring.The initiation of a polymorphic ventricular tachycardia was evidenced by the coupled premature ventricular complex observed in the ECG monitoring screen(Figure 1).

Ventricular tachycardia originating from the His bundle: A case report

BACKGROUND Ventricular tachycardia(VT)commonly occurs among patients with heart failure and can even cause sudden cardiac death.VT originating from the His bundle branch has been rarely reported.We present the case of a patient with VT from the His bundle branch.CASE SUMMARY A 58-year-old female complained of paroxysmal palpitations and dizziness for approximately 6 mo.She had a history of fatty liver and cholecystitis,and carotid atherosclerosis could not be excluded from the ultrasound results.An evaluation of the electrocardiogram obtained after admission showed spontaneous conversion between two different morphologies.The possible electrophysiologic mechanism suggested that the dual-source VT originated from the same source,the His bundle branch.Finally,the His bundle branch was ablated,and a dualchamber pacemaker was inserted into the patient’s heart.No further VT occurred during the 3-year follow-up after hospital discharge.CONCLUSION The diagnosis of VT originating from the His bundle is rare and difficult to establish.The results of this study showed VT originating from the His bundle based on a careful evaluation of the electrocardiogram,and the diagnosis was confirmed by an intracardiac electrophysiologic examination.

Successful Vaginal Delivery after Implantable Cardiac Defibrillator Placement for Management of Ventricular Tachycardia

A 23-year-old female with Tetralogy of Fallot who is 30w6d pregnant presented with palpitations and syncope from an outside hospital.She was found to have ventricular tachycardia.Successful placement of a transvenous implantable cardiac defibrillator allowed for symptomatic control and a subsequent successful vaginal delivery.

A Rare Case of a Primary Cardiac Tumor Presenting as Fatal Ventricular Tachycardia

Primary cardiac tumors are extremely uncommon.Here,we report the case of a patient with a primary left ventricular interstitial tumor presenting with hemodynamically unstable ventricular tachycardia.In response to hemodynamically unstable ventricular tachycardia,an implantable cardioverter-defibrillator was inserted.One month after defibrillator implantation,the patient developed episodes of high ventricular tachycardia that could not be effectively terminated by catheter radiofrequency ablation,thus further confirming that the ventricular tachycardia was induced by the left ventricular interstitial tumor.The patient is doing well on medical therapy to date.

Ventricular Tachycardia Unveiling an Obstructive Cardiomyopathy Complicated with an Apical Aneurysm

Background: We report the case of a 58-year-old hypertensive patient under treatment who presented with a ventricular tachycardia unveiling an obstructive cardiomyopathy complicated with an apical aneurysm. Aim: Highlight the rarity of the case and the difficulty of management. Case Presentation: This patient was transferred from Regional Hospital of Ziguinchor in southern Senegal for a brutal dizzy spell without loss of consciousness. The electrocardiogram showed a wide monomorphic QRS complex regular tachycardia with a rate of 215 beats/min. An external electrical cardio version at 300 joules was applied which led to the recovery of a sinus rhythm on the electrocardiogram. The Doppler echocardiography showed an asymetricalmedio-ventricular hypertrophy with a maximum left intraventricular gradient at 10 mm Hg at rest. The coronarography via the radial artery was normal. The evolution was labeled with a recurrence of the ventricular tachycardia. The patient was then put on amiodarone 200 mg, beta-blocker (bisoprolol 10 mg) and anti-vitamin K (acenocoumarol 4 mg). Facing rhythmic instability, an implantable automatic defibrillator was fitted. No complication has been reported after one year of evolution. Conclusion: HCM with medio ventricular obstruction and apical aneurysm complicated with ventricular arrhythmias is a rare entity. Its management is difficult and controversial.

Rare presentation of intralobar pulmonary sequestration associated with repeated episodes of ventricular tachycardia

Arterial supply of an intralobar pulmonary sequestration(IPS) from the coronary circulation is extremely rare. A significant coronary steal does not occur because of dual or triple sources of blood supply to sequestrated lung tissue. We present a 60-year-old woman who presented to us with repeated episodes of monomorphic ventricular tachycardia(VT) in last 3 mo. Radio frequency ablation was ineffective. On evaluation, she had right lower lobe IPS with dual arterial blood supply, i.e., right pulmonary artery and the systemic arterial supply from the right coronary artery(RCA). Stress myocardial perfusion scan revealed significant inducible ischemia in the RCA territory. Coronary angiogram revealed critical stenosis of proximal RCA just after the origin of the systemic artery supplying IPS. The critical stenosis in the RCA was stented. At 12 mo follow-up, she had no further episodes of VT or angina.

Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia

We report three cases of sustained monomorphic ventricular tachycardia(VT) in the setting of coronary artery disease,resistant to beta-blockers in two patients and to amiodarone in all,successfully terminated by low doses of intravenous(IV) epinephrine.VT was the first manifestation of coronary artery disease in one patient,whereas the other two patients had a previous history of myocardial infarction and were recipients of an implantable cardioverter-defibrillator(ICD).One of these two patients experienced an arrhythmic storm.All had hemodynamic instability at the time of epinephrine administration.A single slow administration of IV epinephrine(0.5 to 1 mg administered over 30 to 60 s) restored sinus rhythm after 30-90 s with only minor side effects.In the ICD patient with recurrent VT and several cardioversions due to transformation of VT to ventricular fibrillation,epinephrine injection led to the avoidance of further shocks.Although potentially harmful,low doses of IV epinephrine used alone or in combination with beta-blocker treatment and electrical cardioversion may be an alternative effective therapy for sustained monomorphic VT refractory to amiodarone.The role of epinephrine in the termination of VT should be studied further,especially in patients pre-treated with amiodarone in combination with beta-blockers.

Novel approaches for the treatment of ventricular tachycardia

Ventricular tachycardia(VT) is a crucial cause of sudden cardiac death(SCD) and a primary cause of mortality and morbidity in patients with structural cardiac disease. VT includes clinical disorders varying from benign to lifethreatening. Most life-threatening episodes are correlated with coronary artery disease, but the risk of SCD varies in certain populations, with various underlying heart conditions, specific family history, and genetic variants. The targets of VT management are symptom alleviation, improved quality of life, reduced implantable cardioverter defibrillator shocks, prevention of reduction of left ventricular function, reduced risk of SCD, and improved overall survival. Antiarrhythmic drug therapy and endocardial catheter ablation remains the cornerstone of guideline-endorsed VT treatment strategies in patients with structural cardiac abnormalities. Novel strategies such as epicardial ablation, surgical cryoablation, transcoronary alcohol ablation, pre-procedural imaging, and stereotactic ablative radiotherapy are an appealing area of res-earch. In this review, we gathered all recent advances in innovative therapies as well as experimental evidence focusing on different aspects of VT treatment that could be significant for future favorable clinical applications.

Discrimination of ventricular tachycardia and localization of its exit site using surface electrocardiography

Differential diagnosis of supraventricular tachycardia (SVT) and ventricular tachycardia (VT) is of paramount importance for appropriate patient management. Several diagnostic algorithms for discrimination of VT and SVT based on surface electrocardiogram (ECG) analysis have been proposed. Following established diagnosis of VT,a specific origination tachycardia site can be supposed according to QRS complex characteristics. This review aims to cover comprehensive and comparative description of the main VT diagnostic algorithms and to present ECG characteristics which permit to suggest the most common VT origination sites.