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Recurrent syncopes in a 68 year old patient prompted further examination in addition to a neurological check. Holter monitoring was performed without antiarrhythmic medication. The ECG showed accelerated polymorphic ventricular tachycardias with degeneration to ventricular flutter and spontaneous termination (left). The tachycardias were documented twice and were sustained for up to two minutes. Coronary angiography revealed 90–95% proximal stenosis of the right coronary artery with an intraluminal filling defect (right). The following day a successful angioplasty of the affected vessel, with implantation of an intracoronary stent (3.5 mm), was performed. No more arrhythmic episodes were documented afterwards. Even the programmed stimulation of the right ventricle was inconspicuous and no further ventricular tachycardias were inducible.
Ventricular tachyarrhythmias in ischaemic heart disease indicate electrical instability of the affected myocardium. Because of poor myocardial tissue perfusion, the conduction system is influenced by modulation of the membrane potential, changes in the refractory time, and appearance of conduction blocks followed by re-entry mechanisms. Thus, high degree ventricular arrhythmias can occur in the absence of a defined electrophysiological substrate such as a myocardial scar.
The question of whether revascularisation such as angioplasty or surgical revascularisation can restore the electrical stability remains open. It has been shown that patients with a normal left ventricular function and no inducible ventricular tachycardias at electrophysiological examination after revascularisation benefit from revascularisation.
In our case we assume the polymorphic ventricular tachycardias were successfully treated by angioplasty. This case underlines the necessity of performing a cardiological as well as a neurological examination in patients with recurrent syncopes.