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.