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A 36 year old woman had been involved in a traffic accident because of syncope. A paramedic witnessed the accident by chance. He diagnosed cardiac arrest and started cardiopulmonary resuscitation. ECG recorded by an automatic external defibrillator revealed ventricular fibrillation. Regular sinus rhythm was successfully restored by a single 200 Joule direct current shock (below, ECG at admission). The patient recovered well within one day without any neurological sequelae. She reported a five year history of recurrent episodes of palpitations without previous syncope. ECG evaluation performed by the patients’ general practitioner a few years ago revealed multiple ventricular premature beats. No further cardiac evaluation had been performed in the past.
Coronary angiography revealed normal coronary arteries. Right anterior oblique angiographic projection of the left ventricle (right) revealed four left ventricular microaneurysms. The global left ventricular ejection fraction was 72%. Two dimensional echocardiography, performed by an experienced operator, failed to show abnormalities of cardiac morphology. Implantation of a defibrillator was performed six days following the successful resuscitation.
Severe ventricular arrhythmias may occur in patients with apparently normal hearts and may be associated with inflammatory left ventricular aneurysms of small dimension. Inflammatory left ventricular microaneurysms are often of viral origin (caused by previous myocarditis) and this finding is a consistent cause of the apparently “idiopathic” ventricular fibrillation in this case.