Korean J Crit Care Med.  2014 Nov;29(4):331-335. 10.4266/kjccm.2014.29.4.331.

Cardiac Arrest due to Recurrent Ventricular Fibrillation Triggered by Unifocal Ventricular Premature Complexes in a Silent Myocardial Infarction

• Lee DH
• Lee S
• Jung HJ
• Kim SJ
• Seo JM
• Choi JH
• Park JS

• KMID: 2227742
• DOI: http://doi.org/10.4266/kjccm.2014.29.4.331

Abstract

A 51-year-old male patient was referred for a sudden out-of-hospital cardiac arrest. Upon arrival, he was conscious and had no chest pain complaints. There was no abnormality in initial electrocardiographic and echocardiographic examinations. However, episodes of recurrent ventricular fibrillation (VF) were documented on rhythm monitoring. Each VF episode was triggered by an isolated monomorphic ventricular premature complex (VPC). Suspecting idiopathic VF, emergency radiofrequency catheter ablation was planned for the VPCs. However, when coronary angiography was performed to exclude silent ischemia, the results showed a total occlusion of the right coronary artery posterolateral branch, which is thought to supply the left ventricular inferior and septal wall. After successful reperfusion, VF episodes and the triggering VPCs disappeared. We are documenting this case to emphasize the potential for silent myocardial infarction to cause out-of-hospital sudden cardiac arrest even in a patient without any symptom or sign of acute coronary syndrome.

Keyword

myocardial infarction; out-of-hospital cardiac arrest; ventricular fibrillation; ventricular premature complexes

MeSH Terms

Acute Coronary Syndrome
Catheter Ablation
Chest Pain
Coronary Angiography
Coronary Vessels
Death, Sudden, Cardiac
Echocardiography
Electrocardiography
Emergencies
Heart Arrest*
Humans
Ischemia
Male
Middle Aged
Myocardial Infarction*
Out-of-Hospital Cardiac Arrest
Reperfusion
Ventricular Fibrillation*
Ventricular Premature Complexes*

Figure

• 

  Fig. 1. A 12-lead ECG findings at initial presentation. Initial 12-lead ECG shows atrial fibrillation with an isolated VPC. There are J-point elevations (0.1–0.2 mV) with early repolarization patterns in limb leads II, III, and aVF. However, there are no typical ST segment elevation or depression seen in patients with acute coronary syndrome. Documented isolated VPCs has a right bundle branch block configurations in V1, superior axes, and positive QRS deflections in V1–V5, suggesting their inferior or septal wall origin near the cardiac base. ECG: electrocardiogram; VPC: ventricular premature complex; VF: ventricular fibrillation.

• 

  Fig. 2. Documented episodes of VF. Continuous rhythm monitoring shows isolated monomorphic VPCs and the initiation of VF. In each episode, isolated monomorphic VPCs (arrows) with nearly identical QRS complex morphology trigger VFs. VF: ventricular fibrillation; VPCs: ventricular premature complexes.

• 

  Fig. 3. Coronary angiographic findings before and after reperfusion of infarction related artery. Right coronary angiography in the posteroanterior projection (A) before and (B) after balloon angioplasty shows a total occlusion of the small posterolateral branch, which supplies the posterior and posterolateral wall of the left ventricle (arrowheads). Right coronary angiography in the right anterior oblique 35° projection (C) before and (D) after balloon angioplasty also shows the site of acute total occlusion at the level of the left ventricular base (arrows).

Reference

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