RESUMO
A 58-year-old man presented with chest pain and tightness and was diagnosed with a Q-wave anterior myocardial infarction. He then developed pulseless ventricular arrhythmias, which were treated with repeated direct-current shocks and intravenous amiodarone. He underwent emergency cardiac catheterization: stents were deployed in the left anterior descending coronary artery and right coronary artery, and an intra-aortic balloon pump was inserted. Severe refractory cardiogenic shock and incessant ventricular arrhythmias compelled us to place a TandemHeart percutaneous left ventricular assist device 4 hours later. The patient's hemodynamic status stabilized, but the arrhythmias persisted for 36 hours. Multiple doses of intravenous amiodarone and lidocaine and multiple external direct-current shocks were all tried, but these measures failed to terminate the life-threatening ventricular arrhythmias. We performed a pharmacologic block of the left stellate ganglion, and this resulted in a return to sinus rhythm after 1 direct-current shock. To our knowledge, this is the 1st patient with refractory ventricular arrhythmias to have been treated with TandemHeart support and left stellate ganglion block.
Assuntos
Infarto Miocárdico de Parede Anterior/complicações , Arritmias Cardíacas/terapia , Bloqueio Nervoso Autônomo , Coração Auxiliar , Choque Cardiogênico/terapia , Gânglio Estrelado/fisiopatologia , Disfunção Ventricular Esquerda/terapia , Angioplastia Coronária com Balão/instrumentação , Infarto Miocárdico de Parede Anterior/diagnóstico , Infarto Miocárdico de Parede Anterior/terapia , Antiarrítmicos/uso terapêutico , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/fisiopatologia , Terapia Combinada , Resistência a Medicamentos , Eletrocardiografia , Hemodinâmica , Humanos , Balão Intra-Aórtico , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Stents , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular EsquerdaRESUMO
Atrioventricular nodal re-entry tachycardia is the most common form of regular paroxysmal tachycardia in the adult population. This tachycardia is a re-entrant rhythm that uses the anatomic location of the atrioventricular node and its surrounding perinodal atrial tissue. The simplest concept regarding the atrioventricular nodal physiology that allows re-entry is founded upon the postulated existence of 2 atrioventricular nodal pathways with different conduction velocities and refractory periods. Herein, we present the case of a 64-year-old man who had a history of paroxysmal atrial fibrillation; he had a permanent pacemaker for sick-sinus syndrome. He developed a tachycardia-induced cardiomyopathy with a perpetual dual response to the pacemaker stimulus. The tachycardia displayed characteristic dual atrioventricular-nodal physiology that was suppressed by amiodarone therapy, leading to a reversal of the cardiomyopathy. We discuss the mechanisms that surround such phenomena.