Case 2
A 52-year-old man with persistent AF was referred to our center for further evaluation and management. He had exertional dyspnea of NYHA functional class II and a history of hypertension, type 2 diabetes, and transient ischemic attack. His medications included atorvastatin, dabigatran, furosemide, linagliptin, metformin, and telmisartan. A 24-hour Holter tracing demonstrated persistent AF with a mean HR of 41 bpm (minimum 32 bpm, maximum 105 bpm), and repeated NSVT up to a maximum of 20 beats (Figure 1B-a and 2B). TTE showed an LVEF of 60%, LA diameter of 44 mm, and mild pulmonary hypertension. The patient was scheduled for electrical cardioversion for rhythm control. After electrical cardioversion, complete atrioventricular (AV) block was observed (Figure 1B-b). A permanent pacemaker was implanted without any complications, and the patient was discharged with no symptoms. Six months later, he experienced sudden cardiac arrest due to polymorphic VT (Figure 3B). After ROSC, the CAG showed minimal CAD. We replaced the pacemaker with an ICD. Amiodarone was added, and the patient was discharged with no complications. However, he experienced appropriate ICD shocks several times for sustained VT and VF after discharge.