Case report
A 55-year-old man has been sent, by his trusted cardiologist, to our hospital to implant an ICD.
He was affected by paroxysmal atrial fibrillation, not on anticoagulant therapy, because of a CHADsVASC 0, and not on antiarrhythmic therapy, except for propafenone ‘pill in the pocket’, with a family history of Arrhythmogenic Right Ventricular Dysplasia (ARVD) and unobstructed arteries at the invasive coronary angiogram performed two years before. In the previous years he also experienced several presyncopal episodes.
His resting echocardiogram showed a normal left ventricular systolic function, with an ejection fraction of 55%, and a mild bi-leaflet mitral valve prolapse with moderate mitral regurgitation. Interestingly, on parasternal long-axis view, MAD was well seen in the posterolateral LV region of approximately 11 mm (figure 1). No other significant structural abnormalities were seen. The trusted cardiologist decided to carry out a cardiac magnetic resonance, that showed no signs of ARVD and proved the presence of MAD. End systolic cine MR sequences in 4-chamber (figure 2) and 3-chamber view (figure 3) demonstrated annular disjunction of the mitral valve and short-axis Phase-sensitive Inversion Recovery (PSIR) sequences, after contrast injection (figure 4, 5), pointed out late gadolinium enhancement of the posterolateral annular ring and of the posterior papillary muscle.
It was therefore decided to implant a Loop Recorder in the patient, that after several months recorded an episode of fast ventricular tachycardia (TV) at 200 bpm for about 5 seconds without symptoms.
In the light of the above findings, we agreed to implant an ICD and the patient was discharged the day after.
Five months later the patient presented to our hospital because of a single shock of ICD, due to an episode of ventricular tachycardia. The patient was then hospitalized and first treated with intravenous amiodarone and than with amiodarone orally. We performed an ICD interrogation, which confirmed the episode of ventricular arrhytmia, and after three days, during which the patient was stable and asymptomatic, he was discharged home with amiodarone.