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Coronary angioplasty for the control of intractable ventricular arrhythmia
1Department of Cardiology, Escorts Heart Institute and Research Centre, New Delhi, India.
Insights
Intractable ventricular arrhythmias (VAs) after anterior myocardial infarction (MI) can be controlled by percutaneous transluminal coronary angioplasty (PTCA) of the infarct-related artery (IRA). This intervention proved effective even without signs of active ischemia.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Ventricular arrhythmias (VAs) post-anterior myocardial infarction (MI) are typically managed with antiarrhythmic drugs.
- Rarely, VAs can become intractable to standard treatments, posing significant clinical challenges.
Observation:
- Three patients with sustained monomorphic ventricular tachycardia and hemodynamic instability post-anterior MI were refractory to multiple therapies including antiarrhythmic drugs, magnesium, cardioversion, pacing, and IABP.
- Despite no clinical signs of ongoing ischemia and angiographic evidence of akinetic areas, the infarct-related artery (IRA) was identified.
Findings:
- Percutaneous transluminal coronary angioplasty (PTCA) of the IRA in all three patients led to dramatic control of VAs.
- This control was maintained long-term (over 1 year) with standard antiarrhythmic drug doses.
- Patients showed partial improvement in left ventricular (LV) function and negative signal-averaged electrocardiograms for late potentials post-PTCA.
Implications:
- PTCA of the IRA may be a valuable therapeutic option for intractable VAs in extensive myocardial infarction.
- This approach can be effective even when clinical signs of active ischemia or viable myocardium are absent.
- Revascularization of the IRA can significantly improve outcomes in select patients with refractory ventricular arrhythmias post-MI.
Abstract:
Ventricular arrhythmias (VAs) that occur following an acute extensive anterior myocardial infarction (MI) usually respond to conventional antiarrhythmic regimes of treatment. Rarely, the VA may prove intractable to therapy. This report is of three patients who presented at varying time frames (3 h to 10 weeks) following an anterior MI. They exhibited sustained monomorphic ventricular tachycardia and hemodynamic instability despite multiple antiarrhythmic drug therapy, intravenous magnesium, direct-current cardioversion (DCCV), overdrive pacing (in one case), and intra-aortic balloon counterpulsation (IABP). Although there was no clinical evidence of continuing ischemia and although coronary angiography that was done in each case showed the infarct-related artery (IRA) to subtend akinetic areas on left ventricular (LV) angiogram, percutaneous transluminal coronary angioplasty (PTCA) of the IRA was done in all three cases. Reestablishing patency of the IRA helped in controlling the VA dramatically with average therapeutic doses of antiarrhythmic drugs. All three patients showed this control to have been maintained over a follow-up period of more than 1 year, with partial improvement in LV function and signal-averaged electrocardiogram negative for late potentials. Thus, in patients with extensive infarction and intractable VA, PTCA of the IRA may provide control of VA even in the absence of clinical signs of active ischemia or viable muscle mass.