Case 1
A 61-year-old man repeatedly visited our emergency room (ER) for dyspnea
of New York Heart Association (NYHA) class III, which had first
developed four months ago. Heart failure with preserved ejection
fraction (HFpEF) and persistent AF were diagnosed. He had a history of
hypothyroidism and cerebral infarction. His electrocardiogram (ECG)
showed AF with an SVR rhythm (Figure 1A-a). Transthoracic
echocardiography (TTE) showed left ventricular ejection fraction (LVEF)
of 70%, left atrial (LA) diameter of 39 mm, E/E‘ ratio of 31, moderate
aortic regurgitation and mild pulmonary hypertension. Coronary
angiography (CAG) revealed minimal coronary artery disease (CAD). A
24-hour Holter tracing demonstrated persistent AF with a mean HR of 42
bpm (minimum 33 bpm, maximum 64 bpm), and non-sustained ventricular
tachycardia (NSVT) of up to 5 beats (Figure 2A). His medications
included atorvastatin, furosemide, indapamide, levothyroxine,
perindopril, spironolactone, trimetazidine, and warfarin. Despite
decongestive treatment with an increase in diuretics, his dyspnea did
not improve. Therefore, electrical cardioversion was attempted to
improve his symptoms. AF was terminated by electrical cardioversion, but
junctional rhythm under 40 bpm persisted (Figure 1A-b). Finally, a
permanent pacemaker of the DDDR type was implanted without any
complications. However, after the procedure, the patient abruptly lost
consciousness and the pulse was not palpable during transfer of the
patient to the intensive care unit. The ECG monitor showed asystole.
Cardiopulmonary resuscitation (CPR) and intubation were performed
immediately. The rhythm strip in the pacemaker showed sustained VT,
which had degenerated to VF (Figure 3A). Although his pacing rhythm was
restored by CPR and repeated defibrillation under the support of
extracorporeal membrane oxygenation, he eventually deteriorated and died
the next day due to intractable heart failure.