Acute management
At admission, the bedside echocardiography revealed a left ventricular ejection fraction (LVEF) of 10 %. Within 1 hour of admission, the patient’s condition degenerated gradually, and eventually went into cardiac arrest with PEA (pulseless electrical activity). Rescue cardiac resuscitation was then performed at the time. An emergency coronary angiography and electrophysiology study were then performed, confirming the intact coronary arteries and diagnosis of orthodromic atrioventricular tachycardia (AVRT) with a left lateral accessory pathway (AP) and the concomitant atrial tachycardia. As radiofrequency energy was being delivered to eliminate the accesory pathway via the retrograde approach (Figure 2), the elevation of the ST interval over the leads V1-V3 and the inferior leads was documented and within a few seconds, the sinus rhythm deteriorated into ventricular fibrillation. (Figure 3) Defibrillation with cardio-pulmonary resuscitation was performed and percutaneous cardiopulmonary support (PCPS) was initiated for unstable hemodynamic status. After restoring sinus rhythm with defibrillation, the elevation of ST interval was then again noted. Under the suspicion of coronary injury or spasm, a repeat angiogram was performed, which showed an intact coronary system. As the patient’s condition deteriorated dramatically, we put him on extracorporeal support and stopped the procedure with partial success in controlling the tachycardia.