Question: Surviving the storm: ventricular fibrillation in the left ventricle assist device era

This Spot the Diagnosis article refers to ‘Answer: Surviving the storm: ventricular fibrillation in the left ventricle assist device era’, by G. Campos et al., https://doi.org/10.1093/ehjacc/zuae026.

We present the case of a 69-year-old man with a history of genetic dilated cardiomyopathy (Filamin-C mutation) and recurrent heart failure hospitalizations. After careful evaluation by the transplant team, he was not deemed eligible for cardiac transplantation because of concomitant pulmonary hypertension. Due to severe heart failure hospitalizations despite guideline-directed medical and device therapy, he received mechanical cardiac support with a left ventricle assist device (LVAD) as a bridge to decision. After LVAD implantation, the primary prevention cardiac resynchronization therapy defibrillator (CRT-D) lead became dysfunctional and the CRT-D generator at the end of life. Taken into consideration no history of prior ventricular arrhythmias, a conservative management (i.e. no system modifications) was decided by the team. During the follow-up, the pulmonary hypertension was resolved, and he was listed for cardiac transplantation.

In one of his scheduled follow-up appointments, 1 year after surgery for the LVAD, the patient reported a 2-week history of dizziness and fatigue. He also noted three low flow alarms in the prior week. His routine electrocardiogram is shown below (Figure 1).

Figure 1

Routine electrocardiogram.

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Question

What would be the most appropriate next step?

1. Urgent coronary angiography

2. Adjust LVAD parameters (increase pump speed)

3. Urgent cardiac defibrillation

4. Intravenous amiodarone loading

Funding

None declared.

Data availability

No new data were generated or analysed in support of this research.

Author notes