Atrial Tachyarrhythmias With Ultra-Rapid Ventricular Response and Sudden Death in Patients Without Structural Heart Disease

Background

Sudden cardiac death (SCD) is generally associated with life-threatening ventricular arrhythmias. Supraventricular arrhythmias are an accepted cause of SCD in Wolff-Parkinson-White syndrome and complex congenital heart disease. However, the role of atrial tachyarrhythmias (ATAs) in SCD in patients with structurally normal hearts is unclear.

Objectives

The goal of this study was to present data on resuscitated patients without structural heart disease (SHD), experiencing recurrent implantable cardioverter-defibrillator (ICD) shocks, who share common clinical and electrical features suggesting that ATAs can cause SCD.

Methods

We describe the clinical characteristics and ICD analysis of syncopal events terminated with shock delivery in 5 young SCD survivors without SHD. Details on the follow-up after ablation of the arrhythmia causing the syncopal episode are also reported.

Results

In all patients (4 male, 1 female; median age 23 years; age range 15-47 years), a surface electrocardiogram recording in the resuscitation setting suggested ventricular fibrillation. After the index event, all patients exhibited recurrent arrhythmic syncopal episodes in a setting of elevated adrenergic tone, treated with ICD shocks. ICD interrogation suggested ATAs (atrial fibrillation in 4 patients, atrial tachycardia in 1 patient), conducting to the ventricles at rates approaching 300 beats/min, as the underlying arrhythmia leading to the syncopal events. ATA ablation abolished episodes of arrhythmic syncope and shock delivery in all patients after a median follow-up of 34 months. No patient died suddenly during follow-up.

Conclusions

Common clinical and electrical features define a distinct entity of SCD caused by ATAs with ultra-rapid ventricular response in otherwise healthy patients. Catheter ablation of the ATA is an effective treatment in these patients.