Sustained Ventricular Fibrillation in a Conscious Pediatric LVAD Patient

Introduction Non-sustained ventricular tachycardia (NSVT), defined by ventricular tachycardia lasting less than 30 seconds, is common in patients with left ventricular assist devices (LVADs)​. Ventricular tachy-arrhythmias (VAs) such as sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) are uncommon but carry a significant risk of morbidity and death. Case Report A 16-year-old male underwent continuous flow LVAD implantation after presenting with end stage heart failure due to dilated cardiomyopathy. Prior to LVAD, he had an increasing burden of NSVT, which improved post-LVAD insertion. On post-op day 11, he developed palpitations related to sinus tachycardia and monomorphic NSVT. He remained conscious with clinical signs of adequate peripheral perfusion. The VAD flows fell from 5.2 L/min to 1.9 L/min secondary to the effects of the VA on the right ventricle (RV). The VAs then deteriorated into sustained polymorphic VT followed by VF (Image 1). He continued to answer questions appropriately but complained of dizziness and visual changes. Medical management included lidocaine, calcium, magnesium, amiodarone, and epinephrine for RV support. In addition, he received 4 defibrillations, the last of which successfully converted him to sinus rhythm. He did not require chest compressions and maintained adequate cardiac output throughout. He underwent cardiac catheterization which confirmed normal coronary arteries and enabled optimization of LVAD settings. He was discharged home 15 days later on LVAD support, with amiodarone, metoprolol and a home automated external defibrillator. He remains well 10 months later with no further events. VF, a potentially life-threatening arrhythmia, was remarkably well tolerated in a teenager on LVAD support despite some evidence of RV compromise. This case highlights the importance of improved risk stratification of NSVTs in the LVAD population to establish the need for anti-arrhythmic medication or implantable cardioverter-defibrillator.