The Plumber Versus Electrician Dilemma: To Bypass or to Defibrillate?

Abstract

We present a unique case of an 80-year-old male who presented to our emergency department following cardiac defibrillation when he was found to be in polymorphic ventricular tachycardia (VT) after a syncopal event while at cardiac rehabilitation. He had known coronary artery disease and had a four-vessel coronary artery bypass graft (CABG) 20 years prior to presentation. He underwent left heart catheterization (LHC) two months prior to the syncopal event for worsening shortness of breath and the decision at that time was to proceed with medical management and intervene with redo-CABG if shortness of breath did not improve or progressively worsened. While admitted under our care after the polymorphic VT event, we faced the dilemma of whether to proceed with redo-CABG first since cardiac ischemia is a common cause of polymorphic VT or whether to insert an implantable cardioverter-defibrillator (ICD) before proceeding with redo-CABG. We present the current literature that addresses ICD implantation for secondary prevention and our approach to this complicated case.

Keywords: cardiac arrest; coronary artery bypass graft; coronary artery disease; implantable cardioverter-defibrillator; polymorphic ventricular tachycardia; syncope.

Figure 1. Basal short-axis view of PET CT with arrows pointing to areas of ischemia in the basal inferolateral region consistent with mid-left circumflex and obtuse marginal 1 artery occlusion.

Figure 2. Vertical long-axis view of PET CT with arrows pointing to areas of ischemia in the apical region consistent with prior total left anterior descending artery occlusion.

Figure 3. The red arrow in the top rhythm strip shows the onset of polymorphic ventricular tachycardia. The bottom rhythm strip shows the continuation of polymorphic ventricular tachycardia.