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Pre-Syncope and Ablation of Moderator Band Premature Ventricular Contraction

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Pre-Syncope and Ablation of Moderator Band Premature Ventricular Contraction Cardiovascular and Metabolic Science Clinical Case Vol. 31 No. 4 doi: 10.35366/97545 October-December2020 Pre-syncope and ablation of moderator band premature ventricular contraction Pre-síncope y ablación de la contracción ventricular prematura con origen en la banda moderadora William-Fernando Bautista-Vargas* Keywords: Ventricular premature ABSTRACT RESUMEN complexes, syncope, catheter ablation. Introduction: Premature ventricular complex (PVC) is a Introducción: El complejo ventricular prematuro (CVP) es frequent diagnostic entity. The underlying cardiac condition is una entidad de diagnóstico frecuente. La condición cardiaca Palabras clave: important to establish a prognosis; in the majority of the cases subyacente es importante para establecer un pronóstico; en la Complejos prematuros with normal heart, PVCs have a good prognosis; nevertheless, mayoría de los casos con un corazón normal, los CVP tienen un ventriculares, síncope, there is a specific morphology of PVC related to serious car- buen pronóstico; sin embargo, existe una morfología específica ablación por catéter. diac issues. The moderator band (MB) PVCs are one of these, de éstos relacionada con problemas cardiacos graves. Los CVP described in a normal heart condition; however, MB- PVC can de la Banda Moderadora (MB) son uno de éstos, descritos en una lead to ventricular tachycardia, ventricular fibrillation, or even condición cardiaca normal; sin embargo, los CVP de la Banda sudden cardiac death. Material and methods: The case of a Moderadora pueden llevar a una taquicardia ventricular, fibri- 25-year-old female patient with very symptomatic, precordial lación ventricular o, incluso, muerte súbita cardiaca. Material palpitations is presented with a history of presyncope. The y métodos: Paciente de 25 años con palpitaciones precordiales workflow showed a normal transthoracic echocardiogram, muy sintomáticas se presenta con un historial de presincopía. normal cardiac MRI, and evidence of bigeminy cardiac El flujo de trabajo mostró un ecocardiograma transtorácico rhythm even an unstable ventricular tachycardia induction in normal, una resonancia magnética cardiaca normal y evidencia an electrophysiology study. She was taken to ablation therapy, de un ritmo cardiaco bigémico; incluso una inducción de taqui- PVCs from the moderator band were found with the highest cardia ventricular inestable en un estudio electrofisiológico. Se activation of -52 ms, the use of intracardiac echocardiogram, llevó a terapia de ablación, se encontraron CVP de la banda and successful ablation in an uncommon PVC location is moderadora con la activación más alta de -52ms, el uso de reported. Results: The radiofrequency ablation therapy with ecocardiograma intracardiaco, y se informa de una ablación 35 watts and 42 oC at the highest activation point on the lateral exitosa en un lugar poco común de CVP. Resultados: La tera- aspect of moderator band (MB) was successful therapy with pia de ablación por radiofrecuencia con 35 watts y 42°C en el the induction of ventricular tachycardia during the application punto de activación más alto en el aspecto lateral de la banda of radiofrequency as a result finish of PVCs. Conclusions: moderadora (BM) fue una terapia exitosa con la inducción de In patients with pre-syncopal, syncopal, and even aborted taquicardia ventricular durante la aplicación de la radiofrecuen- sudden cardiac death secondary to ventricular tachycardia cia como resultado del acabado de los CVP. Conclusiones: En or ventricular fibrillation premature ventricular complexes los pacientes con muerte cardiaca súbita pre-sincopal, sincopal should be addressed with an invasive strategy as RF abla- e incluso abortada secundaria a taquicardia ventricular o tion therapy with the aim of finish a trigger condition. The fibrilación ventricular, los complejos ventriculares prematuros moderator band is considered an arrhythmogenic structure, deben ser abordados con una estrategia invasiva como la terapia PVCs coming from a MB should be addressed as potential de ablación por radiofrecuencia, con el objetivo de terminar death risk and invasive therapy should be considered earlier con una condición desencadenante. La banda moderadora se * Head of Department than antiarrhythmic drugs. considera una estructura arritmogénica, los CVP provenientes of Electrophysiology. www.medigraphic.org.mxde una BM deben ser abordados como un riesgo potencial de St. Sophia Hospital. muerte y la terapia invasiva debe ser considerada antes que los Manizales, Caldas, medicamentos antiarrítmicos. Colombia. Received: 09/06/2020 Accepted: How to cite: Bautista-Vargas William-Fernando. Pre-syncope and ablation of moderator band premature ventricular contraction. 16/10/2020 Cardiovasc Metab Sci. 2020; 31 (4): 131-136. https://dx.doi.org/10.35366/97545 Cardiovasc Metab Sci 2020; 31 (4): 131-136 www.medigraphic.com/cms Cardiovasc Metab Sci 2020; 31 (4): 131-136 @https://dx.. @ 132 Bautista-Vargas William-Fernando. Pre-syncope and ablation of moderator band premature INTRODUCTION echocardiogram, and more recently the cardiac MRI are useful tools to clarify further conditions; he prevalence of premature ventricular even though the structural heart disease has a Tcomplex (PVC) is determinate by a diagnos- hard impact into the prognosis, there is on the tic method. Nowadays more people are been contrary PVC with normal heart related with using a cardiac monitoring wrist for sports or ventricular tachycardia (VT), Ventricular Fibril- lazy activities, and it is common to hear about lation (VF), even Sudden Cardiac Death (SCD).1 PVC in general populations, it seems that in The moderator band premature ventricular a few hours of using a monitoring device as complex is a potentially dangerous entity, even a rule almost everyone will have a PVC, not with a low PVC burden can lead to VT, VF, or specific data have been published regarding the SCD in which cases the prevalence is reported prevalence of wrist monitoring device.1 Other up to 2.5%;5,6 nonetheless, there are no data modalities are reported: in a study of 122,043 in the general population, further investigation subjects using a conventional electrocardiogram is needed to clarify the epidemiological data. (ECG) for about 48 seconds the prevalence of PVC was reported in 0.8%.2 In another study CASE PRESENTATION using a 2 minutes ECG monitoring in 13,456 subjects with no history of heart failure and no A 25-year-old lady presented to the emergency coronary disease, it is reported a prevalence room complained of precordial palpitations of 5.5% of PVC.3 skipped beats like; related to pre-syncopal feel- The symptoms, PVC burden (percentage in ing but nor loss of consciousness. Despite she a 24 hours Holter), and the presence of struc- was on metoprolol 50 mg bid and propafenone tural heart disease are important information 150 mg bid, her symptoms were uncontrolled. to consider to bring the right treatment.1 A In the last year, she was admitted several times broad symptom can be present from the skyped to the emergency room in a different institu- precordial chest palpitations to ventricular tion because of pre-syncope episodes, and tachycardia even ventricular fibrillation and even had an EP study that concludes unstable sudden cardiac death. As a handy approach, ventricular tachycardia which was not able to the PVC burden in a 24 hours Holter (10% or be ablated due to patient due to the instability more) can be used as an indication to proceed of the patient hemodynamic and was planned to further therapy with an invasive strategy if to implant an implantable loop recorder, and there is a cardiomyopathy risk or monitoring keep on medication. During the follow up she medication treatment if the PVC burden is not was transferred to our clinic and complained significant.4 There are different tools to figure of developing much more severe symptoms out if there is or not a normal heart; the ECG with ventricular bigeminy rhythm even with brings the information of underline diseases, the a short coupling interval, so it was planned to Dl 1: VEGM AutoGain (8,7 mm/mV) A B 2: Marcadores Velocidad de barrido: 25 mm/s Dll Figure 1: Dlll A) A twelve aVR aVL ECG showing a B B aVF www.medigraphic.org.mx1582 1520 1586 clinical premature 22 s 23 s 24 s 25 s 26 s 27 s 28 s ventricular complex V1 V2 (red rectangle). Activador B) Implantable V3 cardiac monitor V4 Bradi trace showing a V5 B B B B 1504 1426 1559 1609 bigeminy rhythm. V6 29 s 30 s 31 s 32 s 33 s 34 s 35 s Cardiovasc Metab Sci 2020; 31 (4): 131-136 www.medigraphic.com/cms Bautista-Vargas William-Fernando. Pre-syncope and ablation of moderator band premature 133 10 mV A B Figure 2: MB A) Intracardiac RV echocardiogram (ICE) of the right 5 mV ventricle (RV) showing a moderator band (MB). B) Voltage map scale (0.5-1.5 mv) Voltage Map showing a normal ICE voltage map. 0 mV hospitalize the patient since the medication is apply consolidation points of ablation on that not effective. area, with a good outcome. At the end of the The electrocardiogram showed ventricular procedure, the patient was on sinus rhythm bigeminy, with narrow ventricular premature and the implantable loop recorder interroga- contractions that are negative in DII, DIII, aVF, tion during the follow-up did not show any aVR, positive in aVL, DI, and V1 with a late pre- ventricular premature contractions (Figure 3). cordial transition at V6 (Figure 1). She also had a normal transthoracic echocardiogram, there DISCUSSION was no late enhancement in the cardiac MRI, even a normal coronary angiogram. Finally, the The moderator band first described as a patient was taken for an electrophysiology study structure to protects the right ventricular from since she was symptomatic and there was no distention,7 goes from the lateral free walk to improvement of her condition on medication. the septum, it is a muscle structure that courses All medications were discontinued five half- inferiorly from the right ventricular septum to lives, and on the day of the procedure she was the base of the anterior papillary muscle of the in a fasting state, she was taken to Electrophysi- tricuspid valve,8,9 and it is histologically com- ology Laboratory with a bigeminy rhythm.
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