Allied Professionals (Non-physician submissions only) -> Teaching Case Reports D-PO06 - Poster Session VI (ID 26) Poster

D-PO06-004 - Device-based Electrophysiology Study Of Incessant Wide Complex Tachycardia: Extending The Laboratory To The Bedside (ID 1337)


Background: A 77 year-old-male with ischemic cardiomyopathy (ejection fraction 14%) and a cardiac resynchronization therapy defibrillator (CRT-D) (Amplia, Medtronic plc, Mounds View, MN) presented in cardiogenic shock and incessant wide complex tachycardia (WCT). Presumed ventricular tachycardia (VT) was treated aggressively with intravenous amiodarone and lidocaine without effect, prompting electrophysiology (EP) consult to optimize device tachytherapy programming.
Objective: To highlight the utility of device-based EP study at the bedside for arrhythmia diagnosis and optimization of device programming.
Results: Interrogation demonstrated a WCT (cycle length 516 ms) with device electrograms (EGMs) demonstrating an “A on V” tachycardia. Intrinsic QRS morphology, documented distantly prior to CRT-D implant, did not match the WCT QRS morphology. Ventricular overdrive pacing at 500ms demonstrated ventricular dissociation. Atrial overdrive pacing at 460ms demonstrated atrial dissociation until the 4th paced beat, after which the ventricular rate matched the paced atrial rate with identical ventricular EGMs throughout. Identical ventricular EGMs during atrial pacing and arrhythmia argued for a supraventricular mechanism with aberrancy, while dissociation of both atrial and ventricular tissue from the arrhythmia argued for atrioventricular nodal reentrant tachycardia as the mechanism. Overdrive atrial pacing suppressed the arrhythmia, improving hemodynamics.
Conclusion: Incorporation of electrophysiology study maneuvers to device interrogations can improve diagnostic yield and optimization of device programming.