https://orcid.org/0000-0001-6179-6098
Case report
A 42-year-old male with a history of renal cancer treated by nephrectomy 9 years ago and immunotherapy 2 years ago was referred to our emergency department as a result of recurrent syncope. He had no history of underlying cardiomyopathy or familial history of sudden cardiac death. He reported palpitations preceding syncope.
Few minutes after admission, he presented palpitations recurrence. The electrocardiogram (Panel A) showed an irregular wide QRS tachycardia with atrioventricular (A/V) dissociation and QRS morphology suggesting the diagnosis of ventricular tachycardia (VT). The diagnosis was confirmed during the endovascular electrophysiological study (Panel B) as shown by the A/V dissociation. The transthoracic echocardiography reported normal left ventricular ejection fraction (LVEF). A cardiac magnetic resonance imaging was performed and revealed an intramyocardial mass suggesting a metastatic process with a VT originating from the mass location (Panel C). An endovascular implantable cardioverter defibrillator (ICD) was implanted and beta blocker was introduced. After 1 month, a VT recurrence leading to ICD shock occurred and amiodarone was introduced. Three months after amiodarone introduction, the patient presented another electrical storm. The patient also presented an interstitial pneumonitis leading to amiodarone and immunotherapy arrest. Since the conventional ablation strategy was limited in such situation, we decided to perform a stereotactic radioablation focusing on the LV mass using the CyberKnife technology (Panel D). At 6 months, no VT recurrence occurred despite the lack of antiarrhythmic drug. This case highlights the need for exhaustive investigations regarding VT episodes occurring in young patients and the potential role of stereotactic radioablation to treat VT related to an intramyocardial mass.
