A 28 years old male patient with no known co-morbidities, not addicted to any substance, presented with complaints of palpitations on and off for 1 month, blackouts and dizziness, and sweating for 1 hour before presentation in the emergency room. He was in the usual state of health one month back then he started feeling palpitation, not related to any activity, can occur at rest. He developed blackouts and felt dizzy before presenting in the emergency room. He denied any syncope episode during this interval; he also denied any complaint of shortness of breath or chest discomfort. He also denied any significant history of joint pain, rash, cough or fever, or any flu-like signs and symptoms before this presentation. He also denied any previous history of ischemic heart disease or premature ischemic heart disease in the family or any sudden cardiac death in the family. He denied any previous hospitalization or any drug history.
Electrocardiogram taken at the emergency room showed sustained monomorphic ventricular tachycardia, he was hemodynamically stable. He was given an initial dose of Inj. Amiodarone 150 mg but the rhythm was not reverted then 3 direct cardioversion shocks with were given (of 150J, 200J &250J respectively) and the patient was reverted to normal sinus rhythm. After stabilization, he was transferred to the intensive care unit where he again developed monomorphic ventricular tachycardia. The rhythm was not reverted with amiodarone infusion and then 2 direct cardioversion shocks were given (150J and 200J respectively) and normal sinus rhythm was achieved.
Left heart catheterization was done after stabilizing the patient which showed normal coronary arteries. The electrophysiology team was taken on board and they advised to start Inj. lidocaine instead of amiodarone (1mg/kg IV bolus followed by 1–4 mg/min continuous infusion) as corrected QT interval was 480 ms. EP team also advised replacing potassium and magnesium and started propranolol 20 mg every 6 hours. There were no episodes of ventricular tachycardia episodes after starting above mentioned regimen.
On general physical examination, the young obese male patient lying on the bed is well oriented with time, place, and person and vitally stable. On cardiovascular examination, the apex beat was located at the 5th intercostal space non forceful in nature, and S1 and S2 were audible of equal intensity and no murmur was appreciated. While abdominal, respiratory and neurological system examinations were unremarkable.
On further laboratory investigation, his baseline blood investigations were within normal limits except for his CRP which was initially 5.5 mg/L and later level was 4 mg/L, his potassium was 3.0 mmol/L and magnesium was 1.7 mg/dL, which were replaced and later levels were with normal limits. His ACE (angiotensin converting enzyme) levels were also within the normal range. His echocardiography was done which showed the normal biventricular size and systolic function and normal morphology of cardiac valves and ejection fraction of 65%. Cardiac magnetic resonance imaging (CMR) was carried out showing normal-sized cardiac chambers, normal left ventricular systolic function, and an estimated left ventricular ejection fraction of 60%. The left ventricle basal inferolateral segment was noted as hypokinetic. Basal to mid inferior, anterolateral, and inferolateral segments were relatively thin (4–6 mm) with increased trabeculations. The fat suppression sequence showed fat suppression in mid-myocardial region of in the basal inferolateral segment. Delayed enhancement imaging showed the foci of hyperenhancement in epicardium and mid-myocardium. These findings suggested two differential diagnosis based, it could be either due to post myocarditis changes or undifferentiated hereditary cardiomyopathy. Following is the link to the clip of CMR:
The electrophysiology physician team planned for implantable cardiac defibrillator (ICD) insertion for secondary prevention. The patient was discharged from the hospital after ICD implantation and advised for follow-up in the outpatient department. On his first follow-up, the patient was feeling well and symptoms free and there were no active complaints.