PROCEDURES PERFORMED:
1. Transesophageal echo.
2. Noninvasive program stimulation.
3. DFT testing of BiV ICD Medtronic device.
INDICATIONS FOR PROCEDURE: The patient with monomorphic repetitive ventricular tachycardia that was treated with amiodarone and mexiletine. The patient was followed for about a week after combination of medical therapy was attained. The patient was brought down to the EP lab to reassess the ICD, to make sure that the DFTs are still efficient and also that ATPs are efficient as well.
DETAILS OF PROCEDURE: After obtaining informed consent, the patient was brought to the electrophysiology lab in n.p.o. status. We proceeded with transesophageal echo to scan the left atrial appendage and the left atrium for possible clots. The patient is in chronic atrial fibrillation. He was off Coumadin perioperatively and started on Coumadin recently with a subtherapeutic INR with the last INR of 1.2.
Therefore, we proceeded with evaluation of atrial appendage and left atrium. Not finding any clots, we went on and did program stimulation through that device. We used a cycle length of 400 in S2, S3 and S4, coupled as tightly as the effective refractory period allowed. We ended the study at S1 at 400, S2 at 290, S3 at 230 and S4 at 210. We did not obtain any sustained ventricular tachycardia episodes; although, we did obtain a nonsustained episode of VT that self-terminated.
After NIPS was performed without induction of sustained VT, we went on and proceeded with doing DFTs using the upper limit of vulnerability approach, which consisted of stimulating in the vulnerable period of repolarization with 20 joules and then 25 joules. Twenty joules induced VF, which was successfully treated by the defibrillator with 30 joule shock. Then, we went up to 25 joules and upper limit of vulnerability was tested again. VF was again induced and 30 joule shock was efficient. In view of the fact that two 30 joule shocks were efficient, we elected to not perform any more tests.
CONCLUSION:
1. TEE showing no left atrial appendage clot.
2. Noninvasive program stimulation showing nonsustained VT.
3. DFTs done with upper limit of vulnerability with a 30 joule shock being efficient x2.
RECOMMENDATIONS: The patient can be discharged today. He will be discharged home on the same medication. Will continue the mexiletine at 150 three times daily, amiodarone 300 daily and Coumadin at 3 mg. The patient will be seen again in a week in the clinic. At that time, will check the liver function tests and will also check an INR and TSH.
