Cardiac Arrest of a Physician’s Son with the Wolff-Parkinson-White Syndrome
A 29-year-old white male, the son of an anesthesiologist, had a fast heart rate that required intensive care unit stay 1 day after his birth. He had another episode of racing heart that required emergency room visit while attending college in Virginia. The racing heart stopped before his arrival at the emergency room.
He did not feel well after he got home from playing a hockey game on November 3, 2015. The discomfort continued after he took a shower. His wife, a physician assistant, listened to his heart and noticed fast heart beating. He was instructed to go to the emergency after a phone call to his father.
His wife, who was 37-week pregnant, drove him to the emergency room with a family car. He was talking to his wife in the car and suddenly became unresponsive about one block away from the emergency room. His wife got him to the emergency room in less than 5 minutes. He was found to be in ventricular fibrillation and was successfully defibrillated right away. He required intubation because of the relatively prolonged hypoxic injury.
He had no other medical problem and did not take any medicine. There was no family history of sudden death.
Blood electrolytes and drug testing were normal in the emergency room.
The 12-lead ECG after defibrillation showed atrial fibrillation with normal QRS and S-T segment abnormality (depression on leads II, III, aVF, elevation on lead aVR and aVL).
Emergency coronary angiography showed normal coronary arteries. The echocardiography showed normal cardiac structure and function. He was admitted to the intensive care unit and was put on hypothermia therapy. The 12-lead ECG during hypothermia showed prolonged QT interval but a repeat ECG after discontinuation of hypothermia was grossly unremarkable.
He had the almost complete recovery of the neurological function and was extubated 24 hours after the admission. Because the history strongly suggested tachycardia, the cardiac electrophysiological study with possible ablation was recommended before consideration of an implantable defibrillator.
The EP study showed a left posterior accessory pathway with bidirectional conduction. The antegrade effective refractory period of the accessory pathway was 230 ms at the basic drive cycle length of 600 ms.
The minimal cycle length for maintaining antegrade accessory pathway conduction during induced atrial fibrillation was 210 ms.
The accessory pathway was successfully ablated via the transeptal approach. The patient was discharged the next day. He has been doing well since.
- For a young patient with previous symptoms strongly suggests tachycardia, EP study should be performed after cardiac arrest. ICD should be the last resort.
- The QRS complexes did not show apparent preexcitation after defibrillation in both atrial fibrillation and sinus rhythm. This is somewhat unusual and is likely the result of enhanced AV node conduction in the presence of high sympathetic activities, particularly in a young person.
- Prolonged QT during hypothermia is common.