Cardiac Tumor and Arrhythmia Induced Cardiomyopathy: Management with Pace Suppression

Abstract

<h3>Introduction</h3> Pediatric cardiac tumors are rare and can present clinical challenges, including arrhythmias, which can lead to arrhythmia-induced cardiomyopathy (AIC). Primary management is often surgical resection but may include antiarrhythmic therapy, implantable cardiac defibrillator, ablation, or ultimately heart transplant. We discuss a case in which pace suppression aided in ventricular function recovery and surgical candidacy after a cardiac tumor initially resulted in a wide QRS tachycardia leading to AIC and surgical ineligibility. <h3>Case Report</h3> A cardiac mass was detected in the left ventricle (LV) of a fetus (Figure 1A). At birth, the echocardiogram demonstrated a 2.7 cm x 2.3 cm LV tumor without significant inflow or outflow obstruction (Figure 1B). A cardiac magnetic resonance imaging (MRI) showed a 4 cm x 3.5 cm x 3.1 cm mass infiltrating the inferoseptal LV myocardium (Figure 1C). By one year of age, she developed VT requiring medical treatment. Amiodarone controlled her heart rate, but she had a wide QRS with a left bundle branch morphology that progressed to AIC with an ejection fraction of 20% (Figure 1D). This resulted in poor growth and many ICU admissions. She was considered ineligible for surgery because of her small size and mass burden. Thus, she was referred for cardiac pacing to improve ventricular synchrony by suppressing the left bundle morphology tachycardia. She underwent transvenous placement of a Medtronic single chamber pacemaker and a bipolar lead in the right atrium. Her VT was pace suppressed with settings of AAI at 120 bpm. Her LV dilation and systolic function improved, though she continues with intermittent periods of VT controlled with amiodarone. She is now 4 years old and is scheduled for surgical debulking. <h3>Summary</h3> AIC is a significant complication of pediatric cardiac tumors. Pace suppression via a transvenous pacemaker may be a reasonable alternative approach to achieve stabilization and recovery, particularly in patients who are not surgical or defibrillator candidates.