Electrical Storm after Left Ventricular Pacing Treated by Triple Site Ventricular Pacing and Atrioventricular Node Ablation

概要

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A 74-years-old man had ischemic cardiomyopathy with sustained ventricular tachycardia (VT), and had implantable cardioverter-defibrillator (ICD) insertion 4 years ago. He was admitted to our hospital because of drug refractory heart failure with electrical and mechanical dyssynchrony. Therefore, the system was upgraded to cardiac resynchronization therapy with a defibrillator (CRT-D). Four hours after initiation of biventricular pacing (BiVp), he had electrical storm (ES) caused by VT. VT disappeared under administration of amiodarone and he was discharged. Four months after CRT, he had atrial fibrillation (Af) and experienced severe ES caused by incessant VT, despite oral amiodarone. By turning off left ventricular (LV) pacing, VT disappeared immediately during Af. After Af terminated by CRT-D shock therapy for VT, incessant VT disappeared during sinus rhythm with BiVp. This phenomenon suggested BiVp during Af changed LV activation sequence compared with BiVp during sunus rhythm and LV pacing during Af induced incessant VT. And termination of BiVp exacerbated severe heart failure. So, atrioventricular node (AVN) ablation and triple site ventricular pacing (TriVp) were performed because TriVp changes LV activation sequence compared with BiVp during Af and inhibits VT occurrence, and AVN ablation improves pacing percentage. TriVp and AVN ablation eliminated VT and improved heart failure.