Curative Treatment of Electrical Storm in a Patient with Apical Aneurysm and Thrombus: Aneurysmectomy
Mehmet Rasih Sonsoz*, Ahmet Kaya Bilge, Ali Elitok
Department of Cardiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
*Corresponding Authors: Mehmet Rasih Sonsoz, Department of Cardiology, Istanbul University, Istanbul Faculty of Medicine, Turgut Ozal Street, No:118, Fatih, Istanbul, Turkey
Received: 07 October 2019; Accepted: 23 October 2019; Published: 31 October 2019
Citation: Mehmet Rasih Sonsoz, Ahmet Kaya Bilge, Ali Elitok. Curative Treatment of Electrical Storm in a Patient with Apical Aneurysm and Thrombus: Aneurysmectomy. Journal of Surgery and Research 2 (2019): 258-260.View / Download Pdf Share at Facebook
Aneurysmectomy, Catheter ablation, Electrical storm, ICD shocks, Thrombus, Ventricular tachycardia
ICD-Intracardiac cardioverter defibrillator; VT-Ventricular tachycardia
Left ventricular aneursym is a well-known late complication after myocardial infarction and these patients are at risk for developing ventricular tachycardia which involves the infarct scar. Although it is often amenable to pace termination from ICD, it can lead to electrical storm which may require catheter ablation of the exit sites. However, the procedure has the risk of systemic embolism especially if a ventricular thrombus is present. Herein, we report the management of a young gentleman with incessant monomorphic ventricular tachycardia who had ventricular aneursym and thrombus.
2. Case Report
A 41-year-old gentleman was admitted to the hospital with the diagnosis of anterior myocardial infarction in October 2015. A coronary angiography revealed a total occlusion in proximal LAD segment. The operator performed predilatation and successfully implanted a drug eluting stent into the lesion. After several months, the patient developed dizziness and palpitations, and he was diagnosed with having sustained monomorphic ventricular tachycardia (Figure 1), which was treated with electrical cardioversion. Transthoracic echocardiography disclosed moderate left ventricular systolic dysfunction, left ventricular apical aneurysm and 3 × 3 cm mural thrombus in aneurysm, which was confirmed with 3D echocardiography (Figure 2). Warfarin was added to treatment. For secondary prevention, a VVI-R ICD was implanted in our institution in January 2016.
Ant: anterior wall; inf: inferior wall; IVS: interventricular septum; lat: lateral wall
Until April 2016, he received many times appropriate shocks due to VT, which made him develop suicidal thoughts. We could manage the electrical storm neither with antiarrhythmic therapy nor with cardioversion. We evaluated the chance for a successful catheter ablation, however the embolic risk far outweighed the benefit because of persisting apical mural thrombus. Therefore, we planned urgent aneurysmectomy in order to control the electrical storm. After the successful surgery, the episodes of ventricular tachycardia diminished and apical mural thrombus disappeared. The patient is now in well condition, and no ICD shocks have been observed since 2016.
This case denotes that surgery may be a curative alternative to catheter ablation in a patient with incessant VT and apical thrombus. Cardiac surgery for VT is rarely performed, but has a role in highly symptomatic patients, when antiarrhythmic medications and catheter ablation fails or are not possible . Although Peichl et al.  reported successful catheter ablation in patients with concomitant left ventricular thrombus, we didn’t have the chance to use intracardiac echocardiography. Aneurysmectomy provided both cessation of electrical storm and removal of left ventricular thrombus in our case.
We thank Dr. Ömer Say?n performing the surgery.
Declarations of Interest
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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- Peichl P, Wichterle D, Cihak R, et al. Catheter Ablation of Ventricular Tachycardia in the Presence of an Old Endocavitary Thrombus Guided by Intracardiac Echocardiography. Pacing Clin Electrophysiol 39 (2016): 581-587.