Ventricular Tachycardia Storm After Standard Radiofrequency Pulmonary Vein Isolation

Patient: Male, 69 Final Diagnosis: Ventricular tachycardia storm post PVI ablation Symptoms: Recurrent premature ventricular contractions at 180–200 bpm rate that progressed into a VT storm Medication: — Clinical Procedure: Radiofrequency PVI ablation Specialty: Cardiology OBJECTIVE: Unknown ethiology BACKGROUND: The occurrence of ventricular arrhythmias (VAs), particularly premature ventricular complexes, following pulmonary vein isolation (PVI) is a documented phenomenon, but monomorphic scar-related ventricular tachycardia (VT) following PVI is an unusual phenomenon. In this case report, we present a case of new-onset VA after radiofrequency PVI in a patient with no prior history of sustained VTs. CASE REPORT: Our patient was a 69-year-old man with a history of symptomatic persistent atrial fibrillation, with an apparently structurally normal heart with subtle regional wall motion abnormalities. He underwent radiofrequency directed pulmonary vein isolation ablation. On the night of an uneventful procedure, the patient for the first time experienced a sustained ventricular tachycardia that exacerbated into a VT storm. Each arrhythmia was terminated by cardioversion due to hemodynamic instability. Antiarrhythmic treatment with lidocaine was initiated immediately. The patient settled from sustained ventricular arrhythmia and received further ablation to monomorphic ventricular tachycardia. CONCLUSIONS: The incidence of ventricular ectopics after PVI ablation has been previously described, but a sustained monomorphic ventricular storm has not been reported before with RF ablation. We attribute the pathophysiology to an increase in myocardial excitability and/or ventricular autonomic modulation. This is a very rare phenomenon, but any subtle imaging abnormality before planning RF-PVI should be taken into consideration.