Abstract P307: A Case Of Dual Tachycardia Presenting With Heart Failure Exacerbation

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Dual tachycardia (DT) is the occurrence of simultaneous supraventricular tachycardia and ventricular tachycardia/fibrillation (VT/VF). With increasing interest in this uncommon arrhythmia due to difficulties with diagnosis and complexity of management, DT is identified in about 9% of double-chamber ICD interrogation. An 81 year old male with history of hypertension, ischemic cardiomyopathy status-post BiV AICD presented to ED with worsening exertional dyspnea, orthopnea and pedal edema. He was tachycardic (140 bpm) with bibasilar rales. BNP 655 pg/mL, cardiomegaly and pulmonary edema on chest x-ray. EKG revealed atrial fibrillation (AF) with rapid ventricular response. Echocardiogram revealed a reduced left ventricular ejection fraction <20%. He was diuresed with furosemide, diltiazem infusion for rate control and heparin for anticoagulation. During admission, he developed two episodes of monomorphic VT in VF zone and was successfully cardioverted. During the initial episode, he was in AF and had a VT triggered by PVC which was successfully cardioverted to BiV Paced rhythm. However, he remained in AF which was converted to sinus rhythm after a second cardioversion. A repeat EKG revealed sinus rhythm with BiV paced rhythm. He was later transitioned to oral metoprolol, amiodarone to maintain rhythm control and apixaban. Dual tachyarrhythmia can be managed with medical therapy and/or catheter ablation. The termination of the trigger AF/PVC has been shown to reduce the recurrence of VT/VF episodes. Rhythm control for AF with antiarrhythmic therapy can reduce AF and PVC burden, improve BiV pacing, prevent ICD shocks and help reduce heart failure exacerbation.

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