Investigation
The patient presented to the hospital with incessant refractory tachycardia, acute decompensated heart failure symptoms, and sudden cardiac arrest. It is not uncommon for arrhythmias to cause acute heart failure, and the diagnosis was further supported by the elevated NT-proBNP (364 pg/ml) and the reduced ejection fraction of only 10% at our emergency department. Emergency electrophysiology study and ablation were initiated to terminate the cause and reduce the burden of a fast heart rate on the failing heart. However, the procedure was further complicated by ventricular fibrillation (VF). ST elevation before the lethal arrhythmia, the location of the left lateral portion of the mitral annulus, and the normal coronary angiogram that followed yielded the suspicion of left circumflex coronary spasm. In addition, the reduced coronary flow during fast heart rate and the acutely failing systolic function renders the heart more propensity for ventricular arrhythmias such as VT/VF.