Successful treatment with ivabradine for haemodynamically unstable junctional ectopic tachycardia occurring early after ST-elevation myocardial infarction

Abstract

Junctional ectopic tachycardia (JET) is a relatively uncommon arrhythmia predominantly observed in infancy, often occurring after congenital heart surgery. Although JET is rare in adults, it can occur in the presence of myocardial ischaemia. We describe a woman in her early 70s who presented with multivessel ST-segment elevation myocardial infarction and underwent percutaneous coronary intervention on left anterior descending artery and right coronary artery. She developed JET on the second day, resulting in haemodynamic compromise. Despite initial treatment attempts including amiodarone and beta-blocking agents proving insufficient in controlling JET, we successfully managed by administering ivabradine. Subsequently, she was discharged with recovered cardiac function without recurrence of JET. JET often proves refractory to multiple antiarrhythmic agents and can lead to unfavourable outcomes. Several case reports have demonstrated the effectiveness of ivabradine in treating JET during infancy, which can also be an effective therapeutic option for adult without adversely affecting haemodynamics.

Keywords: Arrhythmias; Interventional cardiology; Ischaemic heart disease.

Figure 1

The 12-lead ECG on admission showed sinus tachycardia with ST-elevation in leads III, aVF, and V2-6, and Q waves in leads V1-6.

Figure 2

The initial coronary angiography identified occlusion in the proximal RCA ((A)—arrowheads), and critical stenotic lesion in the proximal and mid LAD ((B, C)—arrowheads). An Impella CP assist device was inserted (arrows in (D–F)), and an emergency PCI was performed, deploying DES in both the LAD and RCA, resulting in successful revascularisation (D–F). DES, drug-eluting stents; LAD, left anterior descending artery; PCI, percutaneous coronary intervention; RCA, right coronary artery.

Figure 3

The 12-lead ECG on the second day showed narrow QRS tachycardia.

Figure 4

Clinical coarse on acute phase. Emergence of narrow QRS tachycardia (asterisk). Repetition of sinus rhythm and narrow QRS tachycardia (dagger). Conduction of electrophysiological study (double dagger). Insertion of atrial overdrive pacing lead through coronary sinus (section). Start of ivabradine administration (double pipe). BP, blood pressure; CI, cardiac index; HR, heart rate.

Figure 5

Electrophysiological study. Heart rate during junctional ectopic tachycardia (135 beats/min) was a slight increase compared with sinus rhythm (123 beats/min).