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.

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.

Rare narrow QRS tachycardia with atrioventricular dissociation: A case report

BACKGROUND Most Mahaim fibers are right free-wall atriofascicular accessory pathways with only antegrade conduction.Concealed Mahaim fiber is not very rare;however,concealed nodoventricular fiber is a very rare kind of retrograde accessory pathway in supraventricular tachycardia with atrioventricular(AV)dissociation.Only a few cases about successful ablation of the nodoventricular accessory pathway have been reported.We describe the case of a 32-year-old woman who underwent an electrophysiology study and radiofrequency(RF)ablation of a rare narrow QRS tachycardia with AV dissociation.CASE SUMMARY A 32-year-old woman with a history of paroxysmal palpitation was admitted to our hospital for RF ablation.Electrocardiography revealed a narrow QRS complex tachycardia with the same morphology in sinus rhythm.Echocardiography showed no structural heart disease.A right-sided concealed AV accessory pathway and a right-sided concealed nodoventricular accessory pathway were involved in the orthodromic atrioventricular reciprocating tachycardia.His bundle-ventricular interval during tachycardia was the same as that in sinus rhythm.The tachycardia could be initiated and entrained by ventricular pacing.Premature right ventricular stimulus introduced during the His-bundle refractory period when tachycardia occurred was able to advance the next atrial potential.The earliest atrial activation was mapped near the proximal slow AV nodal pathway.RF ablation of both accessary pathways was successfully performed under the guidance of a three-dimensional mapping system by recording the earliest retrograde atrial potential,and tachycardia could no longer be induced.CONCLUSION Narrow QRS tachycardia with AV dissociation is inducible by concealed nodoventricular fiber and ablated by recording the earliest retrograde atrial potential.

MRI-guided ablation of wide complex tachycardia in a univentricular heart

Magnetic resonance imaging can be used for preprocedural assessment of complex anatomy for radiofrequency(RF) ablations,e.g.,in a univentricular heart.This case report features the treatment of a young patient with a functionally univentricular heart who suffered from persistent sudden onset tachycardia with wide complexes that required RF ablation as treatment.

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.

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.

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.

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.

Efficacy and economic benefits of a modified Valsalva maneuver in patients with paroxysmal supraventricular tachycardia

BACKGROUND A modified Valsalva maneuver(VM)has been suggested to be superior to the standard VM for conversion of paroxysmal supraventricular tachycardia(PSVT).AIM To evaluate the efficacy and economic benefits of a modified VM in Chinese patients.METHODS Patients with PSVT admitted to our center between October 2017 and September 2019 were randomly assigned to the modified and standard VM groups.Conversion via VM was performed up to three times.The primary outcome of the study was the success rate of PSVT conversion to sinus rhythm.The secondary outcomes included the incidence of adverse events,economic cost during the visit,and the degree of patient acceptance of the treatment.RESULTS Overall,361 patients were enrolled,with 180 allocated to the modified VM group and 181 to the standard VM group.Baseline characteristics were well matched in the groups.Overall,the modified VM group had higher success rates of PSVT conversion after single(47.78%vs 15.38%,P<0.001)and multiple(62.22%vs 19.78%,P<0.001)VM sessions.No significant differences in the incidences of adverse events and rates of patient acceptance were detected between the two groups(both P>0.05).Moreover,the economic cost of the clinic visit was significantly lower for the modified VM group than for the standard VM group(P<0.05).CONCLUSION The modified VM may confer both therapeutic and economic benefits as compared with the standard VM for conversion of PSVT.

Clinical Study on the Treatment of 325 Cases of Atrioventricular Node Reentrant Tachycardia by Radiofrequency Catheter Ablation

In order to improve the efficacy of modified inferior method or middle method of radiofrequency catheter ablation (RFCA) in the treatment of atrioventricular node reentrant tachycardia (AVNRT), the clinical data of 325 cases of AVNRT from March 1992 to Feb. 2000 being subjected to the treatment of RFCA were retrospectively analyzed. The results showed that the successful rate was increased and recurrence was decreased year by year. In the recent 4 years the effective rate was up to 100 %. The complication of three grade of AVB occurred in 3 % and recurrent rate in 9.1 % before March 1996, but both of them were zero in the last 3 years. The time of RFCA procedure and X ray exposure was significantly reduced. It was concluded that ablating more than 3 targets by modified inferior method or middle method with energy titrating and strict endpoint was the crux of obtaining satisfactory therapeutic effects and preventing recurrence.

RADIOFREQUENCY CURRENT CATHETER ABLATION OF THE LEFT ATRIOVENTRICULAR ACCESSORY PATHWAYS WITH PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

Seventy patients with left atrioventricular accessory pathways and paroxysmal supraventricular tachycardia(PSVT) underwent radiofrequency catheter ablation(RFCA). The success rate was 94. 3%. Among these patients,26 had manifest preexcitation syndrome, and 44 had concealed preexcitation. Eighteen patients with concealed preexcitation underwent coronary sinus (CS) pacing, and delta wave appeared in 15. The keys to successful RFCA were correct positioning of the radiofrequency(RF) catheter tip, A/V amplitude ratio, AV interval (in sinus rhythm) and VA interval(during SVT or ventricular pacing). After 1～14 months of follow-up. two patients had supraventricular tachycardia(SVT) recurrence.

CHANGES OF PLASMA ENDOTHELIN AND ATRIAL NATRIURETIC PEPTIDE DURING THE ONSET AND AFTER TERMINATION OF PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

Radioimmunoassays were used to measure the concentration changes of plasma endothelin(ET) and atrial natriuretic peptide(ANP) during the onset and after termination of paroxysmal supraventricular tachycardia(SVT). 30 cases were reviewed and compansons with 42 normal subjects were made. There are very significant differences(P<0.0001) in the concentration changes of both plasma ET and ANP during the onset and 30 minutes after the termination of SVT. During the onset period of SVT. the plasma ET and ANP were markedly elevated and 30 minutes after its termination they were lowered significantly, but their concentrations were still 2-fold higher than ihose of the control group. As the biological effects of ANP and ET are antagonistic to each other. their parallel elevation and lowering of plasma concentrations during and.after the termination of SVT reveal that these 2 hormones parucipate in the pathophysiological process of SVT. This phenomenon is possibly one of the homeostatic regulatory functions in the organism.

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.