Clinical cardiac problems can be very demanding at times. Here is a situation even the toughest will struggle.
A 52 year old man comes with a wide qrs tachycardia with a blood pressure of 90 /70 with class 4 dyspnea .He was restless , trying to sit up because of orthopnea. The ECG showed a definitive ventricular tachycardia with LBBB morphology.The patient was connected the oxygen line , cardiac monitor, oximetery, etc
The consultant on call instructed immediate DC shock and he warned about impending ventricular fibrillation .He casually told the fellow to do a echocardiogram also and rule out any structural heart disease. Even as the staff was arranging the defibrillator , the fellow did a rapid bed side echocardiogram . He was shocked to find a large mobile LV clot with a dilated , severely dysfunctional left ventricle having an EF of 25 % .
Now comes the critical time . Should we shock this man with VT and LV clot?
What will be your option now ?
- I will not mind the LV clot , will go ahead with DC Shock . Let him dislodge his LV clot . If It is his fate let it be !
- Defer the DC shock . Fall back on medical cardioversion like Bretyllium, Amiodarone or magnesium . After all . . . it is not a pulse less VT. He is not in cardiac arrest . He can afford to wait .We can’t risk a stroke .
- Give a low energy shock 25 joules with paddles avoiding the LV apex. .It may not dislodge the apical clot , still VT may be terminated.
- Try overdrive pacing instead of DC shock
- Refer the patient for emergency surgical removal of LV clot
- Suck out the LV clot with a LV suction catheter and plan elective DC version*
- Insert a temporary Aortic filter and shock the patient **
* Such catheters are in preliminary stage of development . Is that true ? ( If no I should get the royalty for the idea ! )
** A loud imagination . Such filters do not exist.( If IVC can be filtered why not Aorta ? )
What was finally done ?
After analysing each of the above , we decided option one ( “Prey the God and shock the heart” ) After all if it is a VF , this issue becomes null and void ! . Luckily God was with us. The patient was reverted to sinus rhythm with 50joules and had no untoward events . He was subsequently anti-coagulated . He is being planned for CRT/ICD therapy
Critical care medicine is all about risk taking .Many times , therapeutic maneuvers confer a significant risk to life comparable to the index problem. But that should not be a deterrent . A careful learned decision is warranted.