C44 VENTRICULAR TACHYCARDIA IN PATIENT WITH PSEUDOISCHEMIC VENTRICULAR SCAR

Abstract

Abstract We describe a case of 76 years old men. He was referred to emergency room for chest pain and short of breath. The medical history escluded pre–existent miocardial infarction, no history of fever and chest pain has been declared,.The electrocardiogram (ECG) showed a 200 pbm tachycardia with right bundle branch and right axial deviation. The transition was in V4 (Fig. 1). The tachycardia was not tolerated and after ineffective administration of amiodarone, the tachycardia was terminated by DC shock (200 J synchronized). We performed an echocardiogram with evidence of minimal ventricular dilatation, the inferior–posterior–lateral akinesia, inferior–posterior scar and severe reduction of ejection fraction (about 30%). For better characterization of the scar, we performed cardio magnetic resonanc imaging with evidence of significative thinning of the left ventricle free wall and trasmural LGE of the of left ventricle free wall suggest ischemic myocardial injury (Fig. 2 a,b,c,d,e). The coronary arteriography was performed without evidence of critical coronary stenosis.We decide to implant a single lead ICD. After one month, because of recurrence of tachycardia, we performed the electrophysiological study. We induced clinical ventricular tachycardia and the electroanatomical mapping highlighted an area of anomalous potentials extended in the infero–posterior and lower–basal region more at the epicardial level. In these areas, at the epicardial level, late potentials were highlighted and the ablation performed making the tachycardia no longer inducible. Despite of evidence of pseudo–ischemic scar localized at the basal portion of ventricle at the cardiac MRI, no critical coronary stenosis has been demonstrated and the arrhythmogenic substrate was exclusively epicardic. The preliminary hypothesis was a MINOCA, not of recent onset considering the negativity of myocardial enzymes at the admission and the absence of acute ischemic changes on post cardioversion ECG.We have therefore also considered forms of previous extensive myocarditis however with the limited longitudinal extension. From what has been described in the literature, the MRI images could also be attributable to a form of left ventricle arrhythmogenic dysplasia even in the absence of involvement of the apical portions. Forms of infiltrative cardiomyopathies such as sarcoidosis should be excluded due to the lack of involvement of the interventricular septum.