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.