An unusual case of sustained ventricular tachycardia from acute pulmonary embolism
Birchak J, Khan A, Singh G, Schuger C, and Maskoun W. An unusual case of sustained ventricular tachycardia from acute pulmonary embolism. Journal of the American College of Cardiology 2020; 75(11):2820.
J Am Coll Cardio
Background Pulmonary embolism (PE) is a known cause of cardiac arrest, typically through pulseless electrical arrest or asystole. Very rarely, PE is linked to ventricular tachycardia (VT). Case A 64 year old male presented with left lower extremity DVT and acute bilateral PE confirmed on CT scan (1A). Echocardiography showed preserved LV EF, an enlarged right ventricle (RV), and McConnell's sign (1B). Pulmonary angiography showed bilateral filling defects (1C). 36 hours after presentation, he had 2 episodes of sustained monomorphic VT with syncope requiring cardioversion. EKG suggested origin from the RV apex (1D), with follow-up EKG being sinus rhythm with PVC's of similar axis (1E). Decision-making This patient was anticoagulated and bilateral catheter directed thrombolysis (EKOS) catheters were placed. Amiodarone was started and an IVC filter was placed for concern of continued embolization despite anticoagulation causing the VT. He was discharged with a Life Vest and had no events 3 months later. Outpatient myocardial perfusion imaging (MPI) and cardiac MRI were normal. He is planned for an EP study to determine if an implantable cardiac defibrillator is indicated. Conclusion Sustained VT from acute PE is rare, and the best management of these arrhythmias is unclear. Case reports suggest ischemia from RV strain and irritation of valve apparatus from clot-in-transit to be the culprit. Further research is needed to determine the best long term management and role of ICD placement in these patients.