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Case Discussion – VTClinton Thurber, MD
Cardiology Fellow - PGY6
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Case 1
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Presentation
• 73yoM presented to the ED complaining of ICD shocks.
• Complex PMHx significant for ICM (s/p 4v CABG 2002, EF 25%), MMVT (s/p VT ablation 2010) c/b ICD shocks despite AAD attempts (amiodarone toxicity, sotalol ineffective), PAD (s/p aortic endograft, L iliac stent), prostate cancer (XRT, no chemo), and COPD.
• Reported palpitations in bathroom earlier in the evening, then abruptly woke up on the floor. Called EMS ICD shock while waiting for them on his porch.
• Temp 100.6, BP 100/53, HR 62, satting well once BiPAP started.
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Presentation
• Physical exam significant for mild anxiety, a soft systolic murmur, clear lungs, and 1+ pitting edema.
• Labs demonstrated AKI on CKD, a macrocytic anemia with no leukocytosis, a therapeutic INR, and negative troponin.
• EKG was A-paced, unchanged from priors. CXR and CT head largely unremarkable.
• Pertinent findings on device interrogation:
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Clinical Course
• Got ASA load, NaCl bolus, and IV morphine for pain.
• Admitted, started on lidocaine and amiodarone gtt.
• Coronary angiography:
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Clinical Course
• EP consulted, stopped amiodarone and converted lidocaine to PO mexiletine.
• Only one (early) recurrence on telemetry:
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Clinical Course
• Blood cultures grew MSSA.
• TEE:
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Differential for WCT
• Ventricular tachycardia
• SVT with aberrant conduction
• SVT with accessory pathway conduction (e.g. WPW)
• V-paced rhythms
• EKG artifact
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Differential for VT
• Structural heart disease• CAD/ischemia• Scar• HCM• DCM• Sarcoid• Amyloid• ARVC• Chagas• Complex congenital• Duchenne MD• Barth syndrome
• Idiopathic
• Inflammation (e.g. myocarditis)
• Catecholamine surge (sepsis, exercise, etc.)
• Anemia
• Adverse drug effects
• Electrolyte disturbances
• Hypoxia
• Heritable channelopathies• Brugada• LQTS• CPMVT
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Who gets an ICD? (Secondary Prevention)
• Prior resuscitated VT/VF arrest w/ no reversible cause.
• Spontaneous sustained VT in chronic heart disease (e.g. the aforementioned conditions).
• Mortality benefit available
• EXCEPTIONS:• Idiopathic
• Channelopathies in lower-risk patients
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Questions/Discussion