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Transcript
ECG & EP Cases Intractable Ventricular Tachycardia Associated With Stress Cardiomyopathy 경희대학교 의과대학 내과학교실 진은선 Eun-Sun Jin, MD, PhD Cardiovascular Center, Kyung Hee University Hospital at Gangdong, Seoul, Korea Abstract A 75-year-old woman presented with medically intractable wide QRS tachycardia. She had experienced chest discomfort during a vertebral procedure and was transferred to our hospital. Electrocardiography showed sustained wide QRS tachycardia, which persisted in various QRS axes despite the repeated administration of electrical shock. Through amiodarone infusion and repeated shock delivery, the cardiac rhythm was stabilized to a sinus rhythm. Thereafter, the sustained ventricular tachycardia, for which electrical shock was necessary, occurred repeatedly for 12 hours, but then decreased in frequency and disappeared in 3 days. Echocardiography revealed akinesia of the entire left ventricular apical segment, and coronary angiography showed minimal coronary disease, which was compatible with a diagnosis of stress-induced cardiomyopathy. The patient recovered with general supportive care. Follow-up echocardiography revealed normalized left ventricular wall motion and systolic function. Key Words: ■ Takotsubo cardiomyopathy ■ tachycardia ■ ventricular Introduction malities of the left ventricular wall. However, the coronary arteries appear normal in such Stress cardiomyopathy (SCM)—also known as cases and the prognosis is good. Patients with Takotsubo cardiomyopathy—is a common clini- SCM also present with QT prolongation on ECG. cal condition with a clinical presentation that However, only a few cases of SCM presenting similar to acute myocardial infarction. Such pa- with ventricular tachycardia (VT) associated with tients may present with chest pain, ST changes long QT have been reported. In the present re- on electrocardiography (ECG), elevated cardiac port, we describe a case of a 75-year-old patient enzyme levels, and regional wall motion abnor- with medically intractable monomorphic VT associated with SCM. Received: 14 August, 2014 Revision Received: September 11, 2014 Accepted: September 14, 2014 Correspondence: Eun-Sun Jin, MD, PhD, Cardiovascular Center, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, Korea. Tel: +82-2-440-6109, Fax: +82-2-440-7242 E-mail: [email protected] Ko, MD, PhD, Division of Cardiology 72 The Official Journal of Korean Heart Rhythm Society Case A 75-year-old woman was transferred to the emergency room of our hospital for chest dis- ECG & EP Cases Figure 1. Sustained wide QRS tachycardia even after an electrical shock. Occasionally, the QRS axis changed after an electrical shock. Figure 2. Spontaneous QRS axis changes during wide QRS tachycardia. comfort that developed during neuroplasty for QRS axis changed, but the wide QRS tachycardia lumbar spinal stenosis. She was receiving medi- persisted (Figure 1). Most of the VTs were mono- cation for diabetes mellitus and hypertension. morphic, but occasionally, the QRS axis changed Upon arrival to the emergency room, her ECG spontaneously (Figure 2). The patient underwent showed a sustained wide QRS tachycardia of 150 electrical shock more than 30 times within 12 bpm. Her blood pressure was 90/50 mmHg. We hours to terminate the recurrent VT. Because the suspected the presence of monomorphic VT, and QT interval of the sinus rhythm was normal (Fig- hence, electrical shock was delivered. After re- ure 3), amiodarone was infused for the recurrent peated administration of electrical shock, the VT. Subsequently, VT changed to the nonsus- Vol.15 No.3 73 ECG & EP Cases A B Figure 3. Electrocardiography in sinus rhythm showed no QT prolongation (A). 1 month later, ECG showed better R wave progression and T wave change without QT prolongation in precordial leads (B). Figure 4. Coronary angiography showing no significant stenosis. 74 The Official Journal of Korean Heart Rhythm Society ECG & EP Cases tained form and then gradually resolved. level was 3.5 mmol/L. Although prolonged QT Thereafter, echocardiography showed akinesia with polymorphic VT is a common ECG finding of the middle and apical wholesegments. Ex- in cases of SCM, monomorphic VT may also de- tensive ischemia of the left anterior descending velop. Because the proposed mechanism of SCM artery was suspected, but the findings were also involves microvascular myocardial ischemia.4,5 compatible with stress-induced cardiomyopathy. Medical treatment for sustained VT can be ad- In addition, coronary angiography indicated no justed according to the VT mechanism. Amio- significant stenosis (Figure 4). darone infusion is not used for treating cases of Amiodarone administration was discontinued torsades de pointes with long QT, but can be used because of the development of QT prolongation for treating cases of monomorphic VT with no QT during drug infusion. With supportive treatment, prolongation that may be associated with micro- the left ventricular function and wall motion nor- vascular myocardial ischemia. malized, and VT did not recur. The patient was Although a patient may experience life-threat- discharged without any medication. ECG which ening sustained VT resulting from SCM, place- was taken 1 month after discharge showed better ment of an implantable cardioverter-defibrillator R wave progression with T wave change without is not recommended because SCM is considered a QT prolongation in precordial leads (Figure 3B). reversible, self-limited disease. Nevertheless, 11% of patients experience symptom recurrence after a Discussion 4-year follow-up period.6 Thus, large-scale, longterm follow-up data are needed to estimate the re- SCM is a commonly encountered disease, char- currence of life-threatening VT caused by SCM. acterized by its initially severe presentation, followed by a mild clinical course. On presentation, it is often misdiagnosed as myocardial infarction. References The most distinguishable clinical aspects of this disease are the absence of coronary artery stenosis and a good prognosis. Although myocardial infarction is the most common cause of sudden cardiac death, the mortality rate of SCM in hospitals ranges from 1% to 2%.1,2 A potentially dangerous clinical presentation of SCM is torsades de pointes coinciding with QT prolongation, which is often accompanied by hypokalemia.3 However, cases of sustained VT causing cardiac death are uncommon. In the present case, the patient showed recurrent, sustained VT of both the monomorphic and polymorphic forms, with the monomorphic form occurring more frequently. In the sinus rhythm, QT was not prolonged and the serum potassium 1. Sharkey SW, Windenburg DC, Lesser JR, Maron MS, Hauser RG, Lesser JN, Haas TS, Hodges JS, Maron BJ. Natural history and expansive clinical profile of stress (takotsubo) cardiomyopathy. J Am Coll Cardiol. 2010;26;55:333-341. 2. Dib C, Prasad A, Friedman PA, Ahmad E, Rihal CS, Hammill SC, Asirvatham SJ. Malignant arrhythmia in apical ballooning syndrome: risk factors and outcomes. Indian Pacing Electrophysiol J. 2008;1;8:182-192. 3. Kawano H1, Matsumoto Y, Arakawa S, Satoh O, Hayano M. Premature atrial contraction induces torsades de pointes in a patient of Takotsubo cardiomyopathy with QT prolongation. Intern Med. 2010;49:1767-1773. 4. Galiuto L, De Caterina AR, Porfidia A, Paraggio L, Barchetta S, Locorotondo G, Rebuzzi AG, Crea F. Reversible coronary microvascular dysfunction: a common pathogenetic mechanism in Apical Ballooning or Takotsubo Syndrome. Eur Heart J. 2010;31:1319-1327. 5. Afonso L, Bachour K, Awad K, Sandidge G. Takotsubo cardiomyopathy: pathogenetic insights and myocardial perfusion kinetics using myocardial contrast echocardiography. Eur J Echocardiogr. 2008;9:849-854. 6. Elesber AA, Prasad A, Lennon RJ, Wright RS, Lerman A, Rihal CS. Fouryear recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol. 2007;50:448-452. Vol.15 No.3 75