A 40 year old women with palpitation found to have complex multiple VPDs and elevated thyroid hormones.
The GP has refered for further management to a cardiologist, frightened by the morphology and frequency of VPDs.
The cardiologist has sent him to a EP guy .I guess he was not briefed well about the patient, and he decided to do , what he is best at .He tried to fix and shoot down the VPDs. The apparemt inappropriate procedure went on, as per the demand of patients and science . Now, let us question the basics .
The question is,
Where will be the focus of VPD in hyperthyroidism?
A. LV apex or septum
B. RVOT
C.Papillary muslce of LV or Intra -cavity
D. It is an invisble microrentry , or automaticity. Focus can be anywhere and can not be loclaised.
E. Technically there can not be a focus, it is simply enhanced adrenergic drive by free T 3 & T 4
Answer
There has to be a focus for every arrhythmia.It is my thinking. Some of my EP colleagues, say once circuit is established the focus looses it value . In systemic causes of cardiac arrhythmia , there need not have a visible focus. Make a Pardon , as of now , I can only frame a question, not the answer.
Final message.
Leave alone the answer to this question, I am sure every physician knows the correct treatment. Treat the cause, forget the manifestation. If some one is adamant he can do a RF ablation …not in the heart , but in thyroid gland.
Postamble
Even though , it is hyperthyroidism, we have a responsibility to rule out any tissue level substrate because, not every hyperthyroid patient throws this much of VPDs. It is highly possible, thyroid hormomes can un-mask a hitherto non -arryhthmogenic myocardial focus.
Dr.S.Venkatesan MD 