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"Focal" ventricular tachycardia: insights from catheter ablation

Mittal S

Heart Rhythm, 2008 Jun;5(6 Suppl):S64-7.
PMID: 18456205 DOI: 10.1016/j.hrthm.2008.03.023

Catheter ablation has come to play an important therapeutic role in the management of some patients with ventricular arrhythmias. An important advance in catheter ablation of ventricular tachycardia (VT) has been the development of three-dimensional catheter-based mapping systems, which permit identification of the tachycardia circuit and facilitate a strategy for catheter ablation. As a result, patients who suffer from "focal" forms of VT have been identified. This can have implications with respect to underlying arrhythmia mechanism, patient prognosis, and therapeutic strategies. The article reviews some insights learned from catheter ablation of focal forms of VT.

Matched MeSH terms: Tachycardia, Ventricular/physiopathology*; Tachycardia, Ventricular/surgery*
Fulltext Ventricular tachycardia storm: a case series and literature review

Chia PL, Loh SY, Foo D

Med J Malaysia, 2012 Dec;67(6):582-4.
PMID: 23770949

INTRODUCTION: Ventricular tachycardia (VT) storm is an uncommon but life-threatening condition. We describe the incidence, causes and management of VT storm among patients admitted to the coronary care unit of a large tertiary hospital.

MATERIALS AND METHODS: Between 1 November 2009 and 30 April 2010, 198 patients were admitted to the coronary care unit and 7 (3.5%) presented with VT storm. A retrospective review of their records was conducted. The mean follow-up period was 268 (196 to 345) days.

RESULTS: The mean age was 67 years and 4 patients were male. One patient had a previous myocardial infarction. All had abnormal left ventricular ejection fraction, median of 30%. Acute myocardial infarction (4 patients) was the most common trigger, followed by decompensated heart failure (1), systemic inflammatory response syndrome on a background of non-ischemic dilated cardiomyopathy (1) and bradycardia-induced polymorphic VT (1). Three patients had polymorphic VT and the rest had monomorphic VT. Intravenous amiodarone, lignocaine, overdrive pacing and intra-aortic balloon pump counterpulsation were useful in arrhythmia control. Three patients underwent coronary revascularization, 3 patients received implantable cardioverter-defibrillators, 1 had a permanent cardiac pacemaker, 1 died during the acute episode. Five out of the 6 survivors were prescribed oral beta-blockers upon discharge. On follow-up, none of the patients had a recurrence of the tachyarrhythmia.

CONCLUSION: Acute myocardial infarction was the main trigger of VT storm in our patients. Intravenous amiodarone, lignocaine, overdrive pacing and intra-aortic balloon pump counterpulsation were useful at suppressing VT storm.

Matched MeSH terms: Tachycardia, Ventricular*
Fulltext Bizarre ECG in head injury mimicking ventricular tachycardia

Loke YK, Lai VM, Tan MH, Gunn A

Singapore Med J, 1997 Apr;38(4):166-8.
PMID: 9269397

Bizarre electrocardiographic (ECG) changes were found in an 18-year-old girl who had a subdural haematoma following head trauma. The initial diagnosis was of ventricular tachycardia (VT) and she was treated with intravenous anti-arrhythmic drugs and electrical cardioversion, but to no effect. It was later concluded that the ECG appearances were not of a ventricular arrhythmia but were the result of the intracranial pathology. ECG abnormalities related to head injuries have been reported on many occasions, and our case report illustrates how this can create difficulties for the attending clinicians.

Matched MeSH terms: Tachycardia, Ventricular/diagnosis*
Fulltext Markers of ventricular tachyarrythmias in patients with acromegaly

Mohamed AL, Yusoff K, Muttalif AR, Khalid BAk

Med J Malaysia, 1999 Sep;54(3):338-45.
PMID: 11045060

Sudden cardiac death is a known complication of acromegaly. Little is known of the exact mechanism leading to sudden cardiac death in these patients. Ventricular tachyarrhythmias may be an important cause. If this is so, clinical markers of ventricular tachyarrhythmias may be more common in this group of patients. The presence of these markers allow better risk stratification among acromegalic patients.

Matched MeSH terms: Tachycardia, Ventricular/blood; Tachycardia, Ventricular/etiology*; Tachycardia, Ventricular/pathology; Tachycardia, Ventricular/physiopathology*
Hepatotoxicity of amiodarone

Jeyamalar R, Pathmanathan R, Wong D, Kannan P

Ann Acad Med Singap, 1992 Nov;21(6):838-40.
PMID: 1295429

Amiodarone, a commonly used antiarrhythmic agent, has numerous adverse effects. The purpose of this case report is to highlight its hepatotoxicity, an unusual complication of long term amiodarone therapy. Our patient is a 76-year-old man with underlying ischaemic heart disease and recurrent ventricular tachycardia. Eleven months after commencing amiodarone, he developed asymptomatic raised aminotransferases which resolved following drug withdrawal. Amiodarone was then reintroduced and four years later, the patient developed hepatomegaly, worsening liver biochemistry and histopathological changes consistent with early cirrhosis. His symptoms improved following discontinuation of amiodarone. However, hepatomegaly and a low serum albumin still persist four years later.

Matched MeSH terms: Tachycardia, Ventricular/drug therapy*; Tachycardia, Ventricular/pathology
Treatment with flecainide for symptomatic and refractory tachyarrhythmias in children

Ismail Z, Alwi M, Lim MK, Murtazam HA, Jamaluddin A

Acta Paediatr Jpn, 1994 Feb;36(1):44-8.
PMID: 8165907

Nine children, aged 2.5 months to 16 years, presenting with tachyarrhythmias were treated with intravenous (i.v.) flecainide, a type 1C antiarrhythmic drug. There were four boys and five girls; seven were supraventricular and two ventricular tachycardias and three had structural cardiac abnormalities. The i.v. dose required to terminate the arrhythmias ranged from 1.0 to 2.4 mg/kg (mean 1.55 mg/kg) although a mean of 1.94 mg/kg per dose was required to maintain sustained sinus rhythm after a single i.v. dose. Eight of the patients--six supraventricular and two ventricular tachyarrhythmias, required maintenance oral flecainide. Oral dosages of 6.7-9.5 mg/kg per day (mean of 7.97 mg/kg per day in three divided doses) were required to effectively prevent the tachyarrhythmias. Intravenous and oral flecainide are safe and effective in terminating supraventricular and ventricular tachyarrhythmias. No evidence of proarrhythmia was found in the patients during follow up of between 5 and 9 months. The present limitation of performing radiofrequency ablation on infants and small children justifies the important place of medical therapy for re-entrant supraventricular tachyarrhythmias.

Matched MeSH terms: Tachycardia, Ventricular/drug therapy*
Fulltext Torsade de pointes and sudden death associated with diabetic autonomic diarrhoea--a case report

Quek DK, H'ng PK

Singapore Med J, 1993 Jun;34(3):266-70.
PMID: 8266190

A 68-year-old diabetic and hypertensive woman presented with chronic autonomic diarrhoea, syncope and palpitations which were associated with QT prolongation and recurrent episodes of torsade de pointes. She was on glibenclamide, indapamide and probucol (for type V hyperlipidaemia). Despite intravenous infusions of potassium, lignocaine and amiodarone, the unstable rhythm persisted. However, intravenous magnesium sulphate with small doses of intravenous propranolol terminated the torsade de pointes. She was stabilised but following discharge she relapsed, and upon re-admission, succumbed to intractable ventricular fibrillation. Early recognition and aggressive treatment of this condition is emphasised. Multiple aggravating factors ie autonomic diarrhoea resulting in severe potassium and magnesium depletion, kaliuretic effect of indapamide, probable QT prolongation associated with diabetic autonomic neuropathy and probucol; probable underlying coronary artery disease and heightened emotional and sympathetic discharge could have contributed to this very unstable ventricular arrhythmia and sudden death.

Matched MeSH terms: Tachycardia, Ventricular/complications
Fulltext Utilization of implantable cardioverter-defibrillators for the prevention of sudden cardiac death in emerging countries: Improve SCA clinical trial

Zhang S, Ching CK, Huang D, Liu YB, Rodriguez-Guerrero DA, Hussin A, et al.

Heart Rhythm, 2020 03;17(3):468-475.
PMID: 31561030 DOI: 10.1016/j.hrthm.2019.09.023

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) are underutilized in Asia, Latin America, Eastern Europe, the Middle East, and Africa. The Improve SCA Study is the largest prospective study to evaluate the benefit of ICD therapy in underrepresented geographies. This analysis reports the primary objective of the study.
OBJECTIVES: The objectives of this study was to determine whether patients with primary prevention (PP) indications with specific risk factors (1.5PP: syncope, nonsustained ventricular tachycardia, premature ventricular contractions >10/h, and low ventricular ejection fraction <25%) are at a similar risk of life-threatening arrhythmias as patients with secondary prevention (SP) indications and to evaluate all-cause mortality rates in 1.5PP patients with and without devices.
METHODS: A total of 3889 patients were included in the analysis to evaluate ventricular tachycardia or fibrillation therapy and mortality rates. Patients were stratified as SP (n = 1193) and patients with PP indications. The PP cohort was divided into 1.5PP patients (n = 1913) and those without any 1.5PP criteria (n = 783). The decision to undergo ICD implantation was left to the patient and/or physician. The Cox proportional hazards model was used to compute hazard ratios.
RESULTS: Patients had predominantly nonischemic cardiomyopathy. The rate of ventricular tachycardia or fibrillation in 1.5PP patients was not equivalent (within 30%) to that in patients with SP indications (hazard ratio 0.47; 95% confidence interval 0.38-0.57) but was higher than that in PP patients without any 1.5PP criteria (hazard ratio 0.67; 95% confidence interval 0.46-0.97) (P = .03). There was a 49% relative risk reduction in all-cause mortality in ICD implanted 1.5PP patients. In addition, the number needed to treat to save 1 life over 3 years was 10.0 in the 1.5PP cohort vs 40.0 in PP patients without any 1.5PP criteria.
CONCLUSION: These data corroborate the mortality benefit of ICD therapy and support extension to a selected PP population from underrepresented geographies.

Matched MeSH terms: Tachycardia, Ventricular/complications; Tachycardia, Ventricular/therapy*