P28 AN OMINOUS FINDING OF BRUGADA PATTERN: FROM PAROXYSMAL ATRIAL FIBRILLATION TO SEVERE TRICUSPID VALVE REGURGITATION

Abstract

Abstract 49 years old male, without family history of sudden cardiac death, subjected in 2010 to effective electrical cardioversion for a first episode of paroxysmal atrial fibrillation. In 2013, a new episode of atrial fibrillation subjected to effective pharmacological cardioversion with flecainide and contextual finding of intermittent Brugada type I pattern, confirmed by ajmaline provocation test. Considering the asymptomaticity of the patient and the negative family history of sudden cardiac death, no indication was given to defibrillator implantation. In 2015 the patient performed an Electrophysiological Study, positive for induction of ventricular fibrillation, in the light of which an ICD was implanted. In the following years regular checks of the device were performed, in absence of activations. In 2021, at the annual checkup, rupture of the leads was documented, resulting in a complete extraction and reimplantation of the device. A few days later the patient was admitted to the Emergency Room for chest pain and worsening dyspnea, signs of initial right heart failure and increased inflammatory markers. In consideration of the anamnestic history, the presence of infective endocarditis was suspected, for which the patient was admitted to the Cardiology ward. The echocardiogram showed severe tricuspid valve regurgitation due to complete flail of the septal flap and rupture of first order tendon cord, probably iatrogenic and consequent to the extraction of the leads. FDG–PET was performed, which ruled out the presence of infective endocarditis, and surgical correction of the valvulopathy and definitive ICD explant was indicated. The surgery consisted of plastic repair of the tricuspid valve, implantation of definitive epicardial bipolar electrodes, isolation of the pulmonary veins for atrial fibrillation ablation and removal of the ICD. Brugada syndrome, starting from the 2013 consensus, can be diagnosed in patients who only feature the type 1 pattern, spontaneous or pharmacologically induced, even in the absence of malignant arrhythmias or family history of sudden death. This leads as a consequence to an increase in the number of patients undergoing invasive procedures and interventions even with low arrhythmic risk, being instead susceptible to the complications that such procedures can fatally provoke.