Chief complaint:
Syncope in the morning of the date of admission
Brief history:
The 42 year-old man has been quite well until Aug. 3, 1999 when he experienced the first attack of
syncope in the morning. He was found to have labored breath and convulsion by his
wife at AM 5:00 on Aug 8. He was brought to the emergency room where electrocardiogram revealed
ventricular fibrillation. He was treated with amiodarone 200mg bid. Despite of the therapy,
another episode of convulsion occurred in the morning of Sep 3. He was sent to the emergency
room again where recurrent ventricular fibrillation
(fig 1)
was noted and cardiodefibrillation
was successfully applied. The electrocardiogram done after defibrillation was shown in
fig 2.
Then he was transferred to our hospital.
Reviewing the history, the patient denied any symptoms suggesting coronary artery disease.
At our hospital, physical examinations revealed that blood pressure was 110/70 mmHg, body temperature
was 36.2ºC, and pulse pressure was 20/min. The chest was symmetrically expanded and breathing sound was
clear. The chest wall had the marker of the DC shock. The heart had regular beats without murmur. The
abdomen was soft. His extremities were freely movable. The neurological examination was normal.
Course and Treatment:
His biochemistry and complete blood count were within normal limit. No elevation of cardiac enzyme
was found. The electrophysiologic study showed inducible non-sustained polymorphic ventricular tachycardia.
The signal-averaged electrocardiogram showed positive late potential. The cardiac catheterization performed
on Sep 6 showed normal contractility of both ventricles. Cardiac magnetic resonance image revealed increased
signal intensity at the myocardium at right ventricular outflow tract. The challenge test for inducing
arrhythmias yielded positive J wave on eletrocardiogram. An ICD was successfully implanted on Sep 10, 1999.
He was discharged on a stable condition. However, frequent ICD defibrillations were complained of which
made him discomfortable and frustrated. He removed the ICD by himself at the night of Nov 3, 1999.
He was admitted to our hospital later for wound infection. Blood culture showed Aeromonas species.
Debridement was performed with secondary closure. Unfortunately, he experienced the attack of
ventricular tachycardia and ventricular fibrillation in the morning of Nov. 28. After defibrillation,
he regained his vital signs.
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