Implantable Cardiac Defibrillator Placement Research Articles

Abstract 14956: Extensive Cardiac Involvement in Laminopathies Diagnosed in Pediatric-Aged Patients: A Single Center Study

Introduction: Lamin A/C ( LMNA ) gene mutations result in a heterogeneous group of inherited conditions termed laminopathies. Cardiac manifestations of laminopathies include atrial and ventricular arrhythmias, atrioventricular conduction disorders, and cardiomyopathy, with or without skeletal muscle involvement. Because this disease is rare and typically presents in adulthood, pediatric data is limited. Methods: We identified patients < 18 years with genetically confirmed mutations in LMNA followed at our center between 2003 and 2021. Clinical phenotypes along with cardiac test results were retrospectively catalogued. Results: We identified 12 patients with a median age of 5 years at diagnosis (IQR 4-11 years) with a LMNA mutation. Nine (75%) patients were male and 10 (83%) had associated skeletal muscle involvement. Of the 12 patients, 10 (83%) developed cardiac manifestations over a median follow up period of 111 months (IQR 91-116 months). Seven patients (58%) had documented arrhythmias (AV block, ventricular/atrial tachycardias) and 3 (25%) underwent pacemaker and/or implantable cardiac defibrillator placement. Three (25%) patients were diagnosed with cardiomyopathy with 1 (8%) requiring a ventricular assist device and 1 (8%) requiring continuous intravenous inotropes and subsequent transplant. Three (25%) patients died during the study period, one awaiting transplant, one from complications post-transplant, and one from non-cardiac causes. Conclusions: Cardiac involvement, specifically cardiomyopathy and progressive conduction system abnormalities, were common in pediatric patients with LMNA mutations. Early genetic diagnosis of laminopathies followed by frequent surveillance for dysrhythmia and dysfunction is necessary for more timely initiation of advanced cardiac therapies to prevent adverse events. More comprehensive phenotype-genotype correlation is strongly needed.

How arrhythmic risk changes over time in patients with low risk Brugada syndrome

Abstract Background Brugada Syndrome (BrS) is an inherited disorder associated with an increased risk of sudden cardiac death (SCD) and is diagnosed by the presence of a Brugada type I ECG pattern, either spontaneous or drug-induced. A spontaneous ECG pattern is one of the two main risk factors for SCD, along with syncope. However, there is still no clear evidence on how and how often to screen patients with drug-induced BrS to detect a spontaneous ECG pattern, therefore allowing to reassess their arrhythmic risk. Purpose To determine how many subjects develop a spontaneous ECG pattern among a pool of patients with low risk BrS (drug-induced pattern without history of syncope at the time of diagnosis) observed through systematic ECG Holter monitoring. Methods We retrospectively collected data for all patients with low risk BrS treated at our center for at least 12 months between 2016 and 2021. Each patient was tested yearly with at least one 12-lead 24-hour ECG Holter monitoring with high precordial leads (V1-V2, V3-V4, V5-V6 respectively in 2nd, 3rd and 4th intercostal space parasternal left and right). In case of spontaneous pattern detection at two recordings, patients underwent electrophysiological study (EPS) and in case of inducible ventricular arrhythmias, implantable cardiac defibrillator (ICD) placement. Results We included 63 patients with low risk BrS. During a median follow-up of 48 months: 1 patient died for SCD (1.6%), 1 experienced syncope (1.6%) and 19 exhibited a spontaneous ECG pattern (30.2%). Of these 19 patients: 18 were males and 5 had a mutation of SCN5A; the average age at the time of spontaneous pattern detection was 48.1±11.5 years. The average number of ECG holters/per patient/per year was 1.1±0.6, the average number of ECG Holters until the detection of a spontaneous pattern was 3.3±1.8, whilst the average number of months in between the diagnosis and the detection of a spontaneous pattern was 43.2±41.1. After the observation of a spontaneous pattern: 6 patients were excluded from further investigation (as they had already undergone EPS or refused), 1 was directly treated with ICD and 12 underwent EPS, 4 of whom consequently underwent ICD placement. Among these 5 patients who underwent ICD placement – 7.9% of the original 63 patients – we observed 1 appropriate ICD intervention (antitachycardia pacing), 1 inappropriate ICD shock and 1 ICD related complication. Conclusions In our population of patients with low risk BrS the detection of a spontaneous ECG pattern is the most common determinant of risk reclassification. Systematic ECG Holter monitoring disclosed the presence of a spontaneous ECG pattern in a relevant number of subjects, allowing to reassess their arrhythmic risk and indication for ICD placement. Our study stresses the importance of periodic evaluation of low risk BrS patients with ECG Holter monitoring and the need for further investigation to define the optimal monitoring strategy. Funding Acknowledgement Type of funding sources: None.

PO-674-05 THE SHOCKING PRACTICES OF PEDIATRIC ELECTROPHYSIOLOGISTS: CONTEMPORARY DFT DATA FROM CIED REGISTRY

Defibrillator threshold (DFT) testing is no longer recommended except in certain circumstances. Data on current national practice pertaining to DFT testing in pediatrics is scarce. To report current implant characteristics, DFT testing practice, and intraprocedural events in pediatric patients undergoing implantable cardiac defibrillator (ICD) placement. We leveraged the pediatric cardiac implantable electronic devices (CIED) registry, a retrospective multicenter study endorsed by PACES, to identify patients (age≤21) who underwent ICD placement between 2017 and 2020. Among 705 patients, 51 underwent new ICD implantation. Median age and median weight at implant were 16 years (IQR 14-18) and 62 kg (53-78) respectively. Cardiomyopathy was diagnosed in 28, congenital heart disease (CHD) in 8, idiopathic VT/VF in 8, channelopathy in 5, and other in 2. An ICD was implanted for secondary prevention in 18 patients. Type of implants were as follows: transvenous in 39, subcutaneous in 8, and epicardial in 4. DFT status was known in 49 patients, of whom 30 (61%) underwent testing. DFT testing was performed in all patients who had a subcutaneous device but there was no difference in those with transvenous vs. epicardial leads (53% vs. 66%, p=0.63). DFT testing was less likely in patients seen at a freestanding Children’s Hospital (48% vs. 87%, p=0.012) but did not vary between diagnoses (CHD 59%, cardiomyopathy 62%, channelopathy 60%, and idiopathic ventricular fibrillation 75%, p=0.68) or type of cardiomyopathy (hypertrophic cardiomyopathy vs. all other types, 62% vs. 55%, p=0.67). Age, weight, mild ventricular dysfunction or greater, history of cardiac arrest, or implant provider were not associated with DFT testing. DFTs failed in 2 patients: inability to induce VT/VF in 1 and inability to defibrillate with an acceptable safety margin in 1. There were no reported complications with DFTs. DFT testing is still performed at implant in the majority of transvenous devices in pediatric patients. Presence of CHD or hypertrophic cardiomyopathy was not associated with higher DFT testing rates. Freestanding children’s hospitals were less likely to perform DFTs.

RARE PRESENTATION OF DISSEMINATED TB: MULTIPLE RING ENHANCING LESIONS IN BRAIN

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cerebral tuberculomas is a rare form of extrapulmonary tuberculosis (TB). Due to lack of tests available for confirmatory diagnosis, the diagnosis is difficult. However, missing the diagnosis could lead to catastrophic consequences. Here, we report a case of disseminated tuberculosis presented with multiple ring enhancing lesions in the brain. CASE PRESENTATION: A 75-year-old male presented with progressive generalized weakness associated with fever and chills for 3 weeks. He has a history of bronchial carcinoid tumor status post radiation therapy, Waldenstrom's macroglobulinemia, heart failure with reduced ejection fraction, implantable cardiac defibrillator placement, coronary artery disease, stroke, and type 1 diabetes. He appeared tired with mild symmetrical lower limb weakness, but there were no meningeal signs. CT of head revealed innumerable ring-enhancing lesions in both cerebrum, cerebellum and brainstem. Analysis of cerebrospinal fluid (CSF) showed lymphocyte predominant pleocytosis (WBC of 253/cumm), elevated protein (155 mg/dl) with low glucose ratio (CSF/serum glucose ratio of 0.4). Empirical treatment for meningitis were started, but intermittent spiking fever persisted. Unfortunately, the patient had a cardiac arrest while he was undergoing brain MRI. Postmortem autopsy revealed multiple necrotizing granulomatous nodules with AFB positive bacteria in multiple organs, including brain, lung, liver, spleen, thyroid, pulmonary and extrapulmonary lymph nodes. Mycobacterium tuberculosis complex was isolated from CSF subsequently. A diagnosis of disseminated TB was made. Upon further investigation, the patient did not have exposure history, except for travelling around the globe when he was young. DISCUSSION: The differential of multiple ring-enhancing lesions in the brain is broad, which include neurocysticercosis, toxoplasmosis, cryptococcosis, bacterial abscess, CNS lymphoma and cerebral metastases. Given the complicated medical history of our patient and lack of risk factor for TB, empirical treatment for TB was not given. In such a clinical scenario, a more sensitive test, e.g. nucleic acid amplification (NAA), would be the deciding factor for initiation of therapy. Unfortunately, there is a lack of data to support the use of NAA in patients at risk for cerebral tuberculoma. Future studies would be warranted to explore the use of NAA in the setting of extra-pulmonary tuberculosis. CONCLUSIONS: Disseminated tuberculosis is a lethal disease if missed. However, diagnosis of disseminated tuberculosis remains a huge challenge, especially when pulmonary symptoms are absent. A high index of suspicion is required to diagnose and treat disseminated tuberculosis. More researches are warranted to expedite the diagnosis of TB. REFERENCE #1: Suárez I, Fünger SM, Jung N, et al. Severe disseminated tuberculosis in HIV-negative refugees. Lancet Infect Dis 2019; 19: e352–e359. REFERENCE #2: Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis 2017; 64:e1–33. DISCLOSURES: No relevant relationships by Gin Yi Lee, source=Web Response No relevant relationships by Kaiqing Lin, source=Web Response No relevant relationships by Guangchen Zou, source=Web Response

A Systematic Review on the Role of Βeta-Blockers in Reducing Cardiac Arrhythmias in Long QT Syndrome Subtypes 1-3.

Long QT syndrome (LQTS) is one of the most common inherited cardiac channelopathies with a prevalence of 1:2000. The condition can be congenital or acquired with 15 recognized genotypes; the most common subtypes are LQTS 1, 2, and 3 making up to 85%-90% of the cases. LQTS is characterized by delayed ventricular cardiomyocyte repolarization manifesting on the surface electrocardiogram (EKG) by a prolonged corrected QT (QTc) interval. The mainstay of treatment for this condition involves in part or combination medical therapy via β-blockers as first-line (or other anti-arrhythmic), left cardiac sympathectomy, or implantable cardiac defibrillator placement. Given the high rate of adverse cardiac events (ACE) or sudden cardiac death (SCD) in this population of patients with this disease, this review seeks to highlight the genotype-specific treatment consensus in β-blocker therapy of the most common subtypes.A database search of PubMed, PMC, and Medline was conducted to ascertain the most recent data in the last five years on the management of LQTS types 1-3 and the role of β-blockers in reducing ACE in these types. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to in the study selection, and selected studies focused on humans, written in the English Language, and within the last five years of LQTS subtypes 1, 2, and 3.Eleven relevant studies were selected after considering inclusion criteria, exclusion criteria, and quality appraisal within the last five years, focusing on β-blocker selection directed based on the subtypes of LQTS. Two meta-analyses, one cohort study, and eight reviews provided significant data that non-selective β-blockers unequivocally are of benefit in these LQTS types. Summary of findings suggested nadolol followed by propranolol yields the best results in LQTS 1, while nadolol would yield the best effect in LQTS 2 and 3.

Gender differences, rates of arrhythmias, cardiac implantable electronic devices, diagnostic modalities among sarcoidosis patients

Abstract Introduction Sarcoidosis is a granulomatous disease with multiorgan involvement. Cardiac involvement may be asymptomatic or present clinically as heart failure, arrhythmias or even sudden cardiac death. Objective We compared gender differences in prevalence of arrhythmias and associated outcomes in patients with sarcoidosis without established coronary artery disease. Methods The United States Nationwide Inpatient Sample was queried from 2010 to 2014 to identify patients with sarcoidosis using ICD-9 diagnosis code in patients >18 years. We excluded patients with a prior history of myocardial infarction, percutaneous coronary intervention and coronary artery bypass graft. Chi-square test was used for statistical analysis. Results The sample consisted of 308,064 patients (Mage = 55.65±11.28 years); they were mostly women 945 (65.2%) and black 957 (46.7%). In-hospital mortality in this cohort was 1,574 (2.5%). The most common arrhythmias was atrial fibrillation 29,850 (9.7%). Prevalence of ventricular fibrillation was 669 (0.2%), ventricular tachycardia 6,184 (2%), complete heart block 1462 (0.5%) and second degree Mobitz type II 245 (0.1%). Sudden cardiac death occurred in 2,059 (0.7%). Rates of various cardiac devices implanted were: implantable cardiac defibrillator (ICD) 1,452 (0.5%), cardiac resynchronization therapy-defibrillator (CRT-D) 553 (0.2%), pacemaker 1259 (0.4%). Rates of endomyocardial biopsy (EMB), radionuclide imaging, and cardiac magnetic resonance imaging were 470 (0.2%), 879 (0.3%), and 224 (0.1%), respectively. Based on gender (male vs. female), the rates of arrhythmias, cardiac device implantation and utilization of diagnostic modalities were: atrial fibrillation (41% vs 59%; p<0.001), ventricular fibrillation (50% vs 50%; p=0.983), ventricular tachycardia (55% vs 45%; p<0.001), complete heart block (48% vs 52%; p=0.3), second degree Mobitz type II (37% vs 63%; p=0.706), sudden cardiac death (38% vs 62%; p<0.171), ICD (56% vs 44%; p<0.001), CRT-D (58% vs 42%; p<0.025), pacemaker (40% vs 60%; p=0.066), EMB (55% vs 45%; p<0.001), radionuclide imaging (32% vs 68%; p=0.403), cardiac MRI (41% vs 59%; p=0.396). In-hospital mortality was higher in females (36% vs 64%; p<0.001). Conclusion In our study, in-hospital death was more common in females. Females had higher rates of atrial fibrillation compared to males who were found to have a higher burden of ventricular tachycardia. Males had higher rates of ICD and CRT-D placement. Males also had EMB performed more commonly than females. Funding Acknowledgement Type of funding source: None

Gender Differences in Rates of Arrhythmias, Cardiac Implantable Electronic Devices, and Diagnostic Modalities Among Sarcoidosis Patients.

IntroductionSarcoidosis is a granulomatous disease with multiorgan involvement. Cardiac involvement may be asymptomatic or present clinically as heart failure, arrhythmias, or even sudden cardiac death. In this study, we compared gender differences in the prevalence of arrhythmias and associated outcomes in patients with sarcoidosis without established coronary artery disease.MethodsThe United States Nationwide Inpatient Sample was queried from 2010 to 2014 to identify patients with sarcoidosis using the International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code in patients >18 years. We excluded patients with a prior history of myocardial infarction, percutaneous coronary intervention, and coronary artery bypass graft. The chi-square test was used for statistical analysis.ResultsThe sample consisted of 308,064 patients (mean age = 55.65 ± 11.28 years); they were mostly women (65.2%) and black (46.7%). In-hospital mortality in this cohort was 2.5%. The most common arrhythmia was atrial fibrillation (9.7%). The prevalence of ventricular fibrillation was 0.2%, ventricular tachycardia 2%, complete heart block 0.5%, and second-degree Mobitz type II (0.1%). Sudden cardiac death occurred in 0.7%. Rates of various cardiac devices implanted were: implantable cardiac defibrillator (ICD) (0.5%), cardiac resynchronization therapy-defibrillator (CRT-D) (0.2%), pacemaker (0.4%). Rates of endomyocardial biopsy (EMB), radionuclide imaging, and cardiac magnetic resonance imaging (MRI) were 0.2%, 0.3%, and 0.1%, respectively. Based on gender (male vs. female), the rates of arrhythmias, cardiac device implantation, and utilization of diagnostic modalities were: atrial fibrillation (41% vs 59%; p<0.001), ventricular fibrillation (50% vs 50%; p=0.983), ventricular tachycardia (55% vs 45%; p<0.001), complete heart block (48% vs 52%; p=0.3), second-degree Mobitz type II (37% vs 63%; p=0.706), sudden cardiac death (38% vs 62%; p<0.171), ICD (56% vs 44%; p<0.001), CRT-D (58% vs 42%; p=0.025), permanent pacemaker (40% vs 60%; p=0.066), EMB (55% vs 45%; p<0.001), radionuclide imaging (32% vs 68%; p=0.403), and cardiac MRI (41% vs 59%; p=0.396). In-hospital mortality was higher in females (64% vs 36%; p<0.001).ConclusionIn our study, in-hospital death was more common in females. Females had higher rates of atrial fibrillation as compared to males, who were found to have a higher burden of ventricular tachycardia. Males had higher rates of ICD and CRT-D placement. Males also had EMB performed more commonly than females.

Appropriateness of Prescription and Safety of Wearable Cardioverter Defibrillators: A Single-center Experience.

IntroductionWearable cardioverter defibrillators (WCD) are recommended for patients with a high risk of sudden cardiac death (SCD) secondary to arrhythmia that have not qualified for placement of an implantable cardiac defibrillator (ICD). This study provides insights into a single-center experience with WCD in terms of its usage and safety.Materials and methodsWe studied all patients that were prescribed a WCD in the Fairview Hospital in Cleveland Clinic Health System, from January 2014 to June 2016. Institutional Review Board of the Cleveland Clinic approved the study. A retrospective chart review was performed to collect data regarding demographics and baseline comorbidities including age, gender, history of hypertension, diabetes, coronary artery disease, and chronic kidney disease. The patients that were lost to follow up in our electronic medical record (EMR) were excluded. Ejection fraction (EF) at the time of diagnosis and follow-up was recorded. The primary outcome was ICD placement at follow up focusing on appropriate use while the secondary outcome was delivery of shock (appropriate or inappropriate) focusing on efficacy and safety of the device. Patients were stratified based on ICD placement. Statistical Package for the Social Sciences (SPSS), version 23 (IBM Corp., NY, USA) was used for the statistical analysis.ResultsWe identified 73 patients with WCD placement. After the exclusion of 23/73 (31.5%) patients due to loss of follow-up, 50 patients were included in the study (n=50). Clinical characteristics showed 66% patients were males, 76% had hypertension, 40% had diabetes, 34% had chronic kidney disease, 56% patient had a New York Heart Association functional status of >II and 34% were on anti-arrhythmic medication. Indication for WCD use was ischemic cardiomyopathy in 23/50 (46%) patients and non-ischemic cardiomyopathy in 27/50 (54%) patients. No ICD was placed in 39/50 (78%) patients and ICD was placed in 11/50 (22%) patients at end time of follow up. Mean age was 59.9 years (95% confidence interval (CI), 55.9 - 63.9 years) in the group with no ICD placement and 63.5 years (95% CI, 56.5 - 70.6 years) in the group with ICD placement. Mean EF in the group with no ICD placement at the time of diagnosis was 25.8% (95% CI, 23.8% - 27.9%) which improved by 18.8% to a mean EF of 44.6% (41.1% - 48.1%) at the follow-up. Mean EF in the group with ICD placement was 32.7% (95% CI, 27.6% - 37.9%) which reduced by 4.1% to mean EF of 28.6% (95% CI, 12.2% - 44.9%) which was statistically significant (p<0.0001). Patients who had no ICD placement were followed for an average of 162 days and with ICD placement for 78 days. There was no difference between ischemic or nonischemic groups in getting the ICD. There were no shocks delivered whether appropriate or inappropriate in our population.ConclusionAlmost a quarter of the patients that were prescribed WCD in our center ended up with an implanted device which demonstrates appropriate use. Equally important was the observed safety of WCDs as a treatment modality with no inappropriate shocks recorded in the followed cohort.

Management of Brugada Syndrome 2016: Should All High Risk Patients Receive an ICD? All High-Risk Patients Should Receive an Implantable Cardiac Defibrillator.

Management of Brugada Syndrome 2016: Should All High Risk Patients Receive an ICD? All High-Risk Patients Should Receive an Implantable Cardiac Defibrillator.

Regression of Normalized Left Ventricular Systolic Function After Discontinuation of Treatment in Patients With Dilated Cardiomyopathy

Regression of Normalized Left Ventricular Systolic Function After Discontinuation of Treatment in Patients With Dilated Cardiomyopathy

Out-of-Hospital cardiac arrest survivors: Long-Term survival and resource utilization

Study objectives: We determine long-term survival rates, functional status, and predictors of implantable cardiac defibrillator (ICD) use for patients who survive to discharge after out-of-hospital cardiac arrest. Methods: This was a retrospective cohort study of out-of-hospital cardiac arrest survivors transported to 2 large suburban community hospitals between January 1993 and December 2002. Data were abstracted from emergency medical services and hospital records about arrest characteristics, including arrest etiology, functional status at discharge using cerebral performance categories (CPC), and 1- and 3-year survival rates. We collated data about hospital interventions, including coronary angiography, echocardiography, electrophysiology studies, and ICD placement. We compared rates or procedures performed before or after January 1, 1998, to assess temporal trends in ICD therapy. Results: There were 112 survivors. They were predominantly men (64.8%), a witnessed arrest (75.9%), and sustained a ventricular tachycardia/ventricular fibrillation (VT/VF) arrest (91.2%). The most common etiologies of arrest were acute myocardial infarction (AMI) (50.5%) or primary VT/VF (27.2%). The majority (83.7%) of patients were discharged with good neurologic function (CPC 1 or 2). Of all patients with known outcomes, 90 (90.0%) were alive at 1 year, and 72 (92.3%) were alive at 3 years. Patients who received an ICD were older (67.4 versus 60.7 years, P=.25), sustained a primary VT/VF arrest (versus AMI VT/VF; 92.0% versus 30.8%, P<.001), and tended toward ICD placement if they had severe left ventricular dysfunction (66.7% versus 44.6%, P=.13). There was no significant difference in the overall rate of ICD placement (54.4% versus 45.2%, P=.43) between pre- and post-1998 periods. Conclusion: Cardiac arrest survivors have good long-term survival and neurologic function. Most patients with a primary VT/VF arrest receive ICD placement. We found no temporal difference in the rate of ICD placement in this cohort. Study objectives: We determine long-term survival rates, functional status, and predictors of implantable cardiac defibrillator (ICD) use for patients who survive to discharge after out-of-hospital cardiac arrest. Methods: This was a retrospective cohort study of out-of-hospital cardiac arrest survivors transported to 2 large suburban community hospitals between January 1993 and December 2002. Data were abstracted from emergency medical services and hospital records about arrest characteristics, including arrest etiology, functional status at discharge using cerebral performance categories (CPC), and 1- and 3-year survival rates. We collated data about hospital interventions, including coronary angiography, echocardiography, electrophysiology studies, and ICD placement. We compared rates or procedures performed before or after January 1, 1998, to assess temporal trends in ICD therapy. Results: There were 112 survivors. They were predominantly men (64.8%), a witnessed arrest (75.9%), and sustained a ventricular tachycardia/ventricular fibrillation (VT/VF) arrest (91.2%). The most common etiologies of arrest were acute myocardial infarction (AMI) (50.5%) or primary VT/VF (27.2%). The majority (83.7%) of patients were discharged with good neurologic function (CPC 1 or 2). Of all patients with known outcomes, 90 (90.0%) were alive at 1 year, and 72 (92.3%) were alive at 3 years. Patients who received an ICD were older (67.4 versus 60.7 years, P=.25), sustained a primary VT/VF arrest (versus AMI VT/VF; 92.0% versus 30.8%, P<.001), and tended toward ICD placement if they had severe left ventricular dysfunction (66.7% versus 44.6%, P=.13). There was no significant difference in the overall rate of ICD placement (54.4% versus 45.2%, P=.43) between pre- and post-1998 periods. Conclusion: Cardiac arrest survivors have good long-term survival and neurologic function. Most patients with a primary VT/VF arrest receive ICD placement. We found no temporal difference in the rate of ICD placement in this cohort.

Management of recurrent ventricular tachycardia with ventricular assist device placement

Life-threatening, recurrent ventricular tachycardia developed in a 54-year-old heart transplant candidate with ischemic cardiomyopathy. The episodes of ventricular tachycardia were refractory to aggressive medical management and implantable cardiac defibrillator placement. A Heartmate left ventricular assist device was implanted, in combination with isolated right coronary artery bypass grafting, which abolished any further episode of ventricular tachycardia. The patient successfully underwent cardiac transplantation 79 days later.