Papworth Everard Hospital – April 2016
From Dr Sergio Bara assessment, Jessica was admitted to Papworth intensive Care Unit on August 16th, 2015. Planned electrophysiology study in 2016. Over the course of her nine days stay at the critical care unit, Jessica made a gradual recovery. Her episodes of poorly tolerated tachycardia were controlled with a combination of intravenous Amiodarone and Beta-blocker. The cardiac function also improved markedly after her arrhythmia was controlled. The last transthoracic echocardiogram performed before her discharge revealed an ejection fraction of between 40-45 %.
From a respiratory point of view, a CT chest scan revealed bilateral pulmonary embolism and pulmonary infarcts. She had further episodes of tachycardia during her stay in the critical care unit. For example, her notes contain several ECGs performed on August 19 revealing a narrow complex tachycardia at around 155 beats per minute. This was a short RP tachycardia which could either be atrial tachycardia, AVRT or atypical AVNRT.
A recent MRI scan has shown that the left ventricle is borderline dilated with normal wall thickness and systolic function. Her right ventricular systolic function is also normal and there is no evidence of infarction or fibrosis. Overall this is reassuring. Unfortunately, Jessica had a hypoxic brain injury and is currently having rehabilitation. There have been some episodes of low blood pressure, bradycardia and therefore her Ramipril and Bisoprolol dosages had to be reduced. She hasn’t had any significant episodes of shortness of breath or sustained palpitations. She did have some episodes of palpitations which are suggestive of the occurrence of ectopic beats.
She had three admissions to hospital in the last six or seven months due to intermittent palpitations. As far as I am aware, no sustained arrhythmia has been electrocardiographically documented but she was found to be having ectopic beats. Her ECG today reveals sinus bradycardia at 57 beats per minute.
lt is possible that she could have had underlying left ventricular systolic dysfunction which then deteriorated due to the incessant or highly recurrent tachycardia. lt is quite rare for a supraventricular tachycardia occurring over a period of up to two weeks to cause such pronounced dysfunction of the heart on its own. I note that she hadn’t had any echocardiogram prior to her admission to Ipswich Hospital.
The Plan. The question arises now whether she should be submitted to an electrophysiology study with the intent of performing an ablation if any substrate was found. I reviewed all of Jessica’s clinical notes and discussed the case with some of my colleagues. We recommend that Jessica has an electrophysiological study to try and exclude any concealed accessory pathway. ln addition to this we will try and induce any arrhythmia and will perform an ablation if indicated. This should be done as a joint procedure. We also recommend that Jessica stops her Amiodarone as she has been taking it for eight months now.
Her heart function is back to normal which is great news from a prognostic point of view. She should continue taking the low dosages of Ramipril and Bisoprolol for the time being. Further reports will follow once we have performed this procedure.
I believe that the best way forward would be to perform an electrophysiological study to try and see whether there are any inducible arrhythmias. lf we find any inducible arrhythmias then our plan would be to perform an ablation on the day to try and prevent them from recurring. Given that I have seen several ECG’s showing the clinical arrhythmia which you had in 2015 we can postpone the cardiac event recorder for now and just proceed with the electrophysiological study.
lf this study is normal then I would suggest some form of monitoring which would either be with a cardiac event recorder or with the AliveCor which you could potentially attach to your iPhone. I would be happy if you could please let us know whether you are in agreement with this strategy.
Papworth Everard Hospital – 2016