Singleton Matthew J, Bhave Prashant D, Beaty Elijah H, Bradford Natalie S, Whalen S Patrick
Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
J Innov Card Rhythm Manag. 2021 May 15;12(5):4501-4505. doi: 10.19102/icrm.2021.120501. eCollection 2021 May.
Ventricular tachycardia storm is associated with high mortality rates and is often refractory to treatment. Historically, few options for treatment have existed in cases when antiarrhythmic drugs fail. We report the case of a patient with incessant ventricular fibrillation (VF) in the postinfarction period that was triggered by premature ventricular contractions (PVCs) that persisted despite normal electrolytes, exclusion of ongoing ischemia, infusions of antiarrhythmic drugs, general anesthesia, full circulatory support with extracorporeal membranous oxygenation, and cardiac sympathetic denervation. Given that the VF appeared to be triggered consistently by a unifocal, short-coupled PVC (consistent with Purkinje fiber-mediated VF), we performed catheter ablation, after which point, the patient experienced no further PVCs or ventricular arrhythmia. This case serves as a reminder of three key teaching points. First, not all VF is created equal, with some cases being chiefly the result of a vulnerable substrate and others being best accounted for by frequent triggers. Second, examining the available electrocardiographic data and appropriately interpreting them can guide the selection of therapies up to and including catheter ablation for treatment-refractory VF. Third, full circulatory support greatly facilitates successful electroanatomic mapping and catheter ablation of unstable ventricular arrhythmias.
室性心动过速风暴与高死亡率相关，且常常对治疗难治。从历史上看，在抗心律失常药物治疗失败的情况下，治疗选择很少。我们报告了一例心肌梗死后持续室颤（VF）的患者，尽管电解质正常、排除了持续缺血、输注了抗心律失常药物、实施了全身麻醉、采用体外膜肺氧合进行了完全循环支持以及进行了心脏交感神经去支配，但仍由室性早搏（PVC）触发。鉴于室颤似乎始终由单灶性、短联律间期的室性早搏触发（符合浦肯野纤维介导的室颤），我们进行了导管消融，此后患者未再出现室性早搏或室性心律失常。该病例提醒了三个关键要点。第一，并非所有室颤都是相同的，有些病例主要是由于易损基质导致，而另一些病例最好用频繁触发因素来解释。第二，检查可用的心电图数据并进行适当解读，可以指导选择包括导管消融在内的治疗难治性室颤的治疗方法。第三，完全循环支持极大地促进了不稳定室性心律失常的成功电解剖标测和导管消融。
