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.

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.

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.

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.

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.

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.

Advanced Anderson-Fabry disease presenting with left ventricular apical aneurysm and ventricular tachycardia

A 54-year-old female with Anderson-Fabry disease(AFD)-R342 Q missense mutation on exon 7 in alphagalactosidase A(GLA) gene- presented with sustained ventricular tachycardia. Imaging confirmed the presence of a new left ventricular apical aneurysm(LVAA) and a significantly reduced intra-cavitary gradient compared to two years prior. AFDcv is an X-linked lysosomal storage disorder caused by GLA enzyme deficiency. The phenotypic expression of AFD in the heart is not well described. Cardiac involvement can include left ventricular hypertrophy(LVH), which is typically symmetric, but can also mimic hypertrophic cardiomyopathy(HCM). Left ventricular apical aneurysm is a rare finding in HCM. We suggest a shared mechanism of LVAA formation in AFD and HCM, independent of the underlying cardiomyopathy. Mechanisms of LVAA formation in HCM include genetic predisposition and long-standing left ventricular wall stress from elevated intra-cavitary systolic pressures due to mid-cavitary obstruction. Both mechanisms are supported in this patient(a brother with AFD also developed a small LVAA). Screening for AFD should be considered in cases of unexplained LVH, particularly in patients with the aneurysmal variant of HCM.

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.

Treatment of refractory ventricular tachycardia with combination of alcohol ablation and radiofrequency ablation

The post-infarcted related ventricular tachycardia (VT) is considered associated with increase in mortality or sudden cardiac death (SCD). Implantable cardioverter defibrillation (ICD) has been the standard therapy for the first or second prevention of SCD after myocardial infarction (MI). Incessant VT, which has poor response to anti-arrhythmic drugs and can cause repetitive ICD shock, is usually a tough problem in clinical practice. According to the guideline, incessant infracted related VT could be treated with catheter ablation.[1] Herein we reported a case of refractory scar-induced VT accompanied with thrombus in the left chamber, which was full with ups and downs during the therapy.

Role of catheter ablation of ventricular tachycardia associated with structural heart disease

In patients with structural heart disease, ventricular tachycardia (VT) worsens the clinical condition and may severely affect the shortand long-term prognosis. Several therapeutic options can be considered for the management of this arrhythmia. Among others, catheter ablation, a closed-chest therapy, can prevent arrhythmia recurrences by abolishing the arrhythmogenic substrate. Over the last two decades, different techniques have been developed for an effective approach to both tolerated and untolerated VTs. The clinical outcome of patients undergoing ablation has been evaluated in multiple studies. This editorial gives an overview of the role, methodology, clinical outcome and innovative approaches in catheter ablation of VT.

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.

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.

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).

Experience on application of transveneous implantable MINI Ⅱ cardioverterdefibrillator for ventricular tachycardia due to right ventricular dysplasia:a report of a case

Objectics: Implantable cardioverter-defibrillator (ICI)is an important mean for treating ventricular tachycardia (VT ) in patients with structural heart diseases .This report deals with our primary experiences in cliical application of transveneous implantable cardioverter defibrillator.Metgids: A 13- year-old male patient with right ventricular dysplasia (ARVD) ). who lhad a failed result from antiarrhythmic drug therapy was implanted with ICD transveneously. Results: During follow. up. the antitachycardia pacing (ATP) did not terminate the first 2 episodes of VT. The episodes of VT were reverted into sinus rhythm by 4 J shock. The patient had a strong uncomfortable sensation :After resettin ATP program . VTs of patient were automaticallly terminated by ICD with ATP therapy many times. Conclusion: ICD implantation is an effective approach for treating VT and reasonable resetting of ATP is needed.

Current Management of Ventricular Tachycardia:Approaches and Timing

Ventricular tachycardia(VT)in the presence of structural heart disease is associated with sudden cardiac death and warrants prompt attention.Implantable cardioverter defi brillators(ICDs)while highly effective in terminating sustained ventricular arrhythmias and reducing mortality,have no effect on the arrhythmia substrate and recurrent shocks for VT termination occur in approximately20%of patients.Shocks worsen quality of life and are associated with progression of heart failure and increased mortality.Antiarrhythmic drugs,mainly in the form of beta-blockers or amiodarone,are moderately effective in reducing ICD therapies but drug intolerance and serious toxicities of amiodarone necessitate drug cessation in a quarter of patients.Catheter ablation has emerged as an effective treatment for control of frequent VT episodes and can be life saving in cases of incessant VT or VT storm.As experience increases,it is being used increasingly earlier,rather than a last resort therapy.Efficacy varies with the nature of the underlying heart disease.Intramural arrhythmia substrate and failure to create permanent ablation lesions remain challenges and repeat procedures are necessary in a third to a half of patients.For idiopathic VTs or PVCs that are symptomatic or worsen LV function,catheter ablation is often an effective therapy.

Successful treatment of systemic sclerosis complicated by ventricular tachycardia with a cardiac resynchronization therapydefibrillator:A case report

BACKGROUND Systemic sclerosis is a rare connective tissue disease characterized by localized or diffuse skin thickening and fibrosis,which usually accumulates in various organs throughout the body.Tachyarrhythmia is a common clinical manifestation of cardiovascular damage in systemic sclerosis patients.However,few studies have reported the use of catheter ablation and an implantable cardioverter defibrillator in patients with systemic sclerosis complicated by ventricular tachycardia.CASE SUMMARY A 39-year woman with an 11-year history of systemic sclerosis was referred to our hospital due to three syncopal episodes in the past 6 mo.The results of an electrocardiogram and a transthoracic echocardiogram revealed ventricular tachycardia and left ventricular systolic and ventricular septum segmental motion abnormalities,respectively.The results of an electrocardiogram showed a sinus rhythm with complete blockage of the left bundle branch.In light of the progressive nature of systemic sclerosis,the presence of a left bundle branch block,and the decreased ejection fraction,a cardiac resynchronization therapydefibrillator was implanted.The patient’s clinical conditions improved,and at the3-mo follow-up,the patient was free of ventricular tachycardia and all cardiac symptoms.CONCLUSION We report the first case of systemic sderosis complicated by ventricular tachycardia that was successfully treated with a cardiac resynchronization therapy-defibrillator.

Ultrasound-Guided Left Stellate Ganglion Blocks for Recurrent Ventricular Tachycardia (Electrical Storm)

Recurrent Ventricular Tachycardia, or Electrical Storm, is a relatively common cause of mortality and morbidity after myocardial infarction. We present a case in which left stellate ganglion blocks were performed under ultrasound guidance in order to alleviate recurrent ventricular tachycardia in a patient requiring extracorpeal membrane oxygenation after myocardial infarction. A medically complex 54-year-old male after two weeks removed from an acute ST elevation myocardial infarction status post stenting and intra-aortic balloon pump placement presented in the cardiovascular intensive care unit with recurrent unstable ventricular tachycardia while on extracorporeal membrane oxygenation and multiple vasoactive infusions. Our acute pain service was consulted by the cardiac electrophysiology service to provide left stellate ganglion blocks in attempt to attenuate electrical storm. Multiple single shot left stellate ganglion blocks were performed on subsequent days with increasing local anesthetic concentrations and volumes successfully providing temporary relief of electrical storm. A left stellate ganglion catheter was eventually placed, and a continuous infusion of local anesthesia was started. The patient experienced complete relief from unstable ventricular tachycardia and no further defibrillations were required. The catheter remained in place for 14 days allowing for extracorporeal membrane oxygenation decannulation without the return of electrical storm. We believe ultrasound guided left stellate ganglion blocks to be a relatively safe means to provide temporary relief of recurrent ventricular tachycardia.

Aortic Sinus of Valsalva Aneurysm Isolation by Radiofrequency Ablation in Outflow Tract Ventricular Tachycardia

Idiopathic monomorphic ventricular tachycardia and premature ventricular complexes (PVCs) commonly arise from the right and left ventricular outflow tracts (VOT). Their mechanism is most commonly triggered activity from delayed after-depolarizations and successful ablation is performed at the site of earliest endocardial activation. Re-entrant mechanisms have been rarely described. We report a case of an otherwise healthy patient who ultimately underwent six electro-physiology studies (EPS) and suffered numerous implantable cardiac defibrillator (ICD) discharges prior to the successful radiofrequency ablation (RFA) of two idiopathic VOT tachycardias. During the sixth EPS, a proximal aortogram demonstrated a left aortic sinus of valsalva (LASV) aneurysm. Subsequntly, a novel and successful RFA strategy of aneurysm isolation was undertaken. The presence of multiple clinical or inducible VT morphologies and the characterization of a VT as re-entrant should raise concerns that a complex arrhythmogenic substrate is present and defining the anatomy with angiography or an alternative imaging modality is essential in achieving a successful ablation strategy.