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The institutional review board (Chengdu Military General Hospital) approved this work and waived the need for informed consent.
In 2013 Date , a 66 Age - year Age - old Age farmer Occupation with a history of ventricular History tachycardia History (VT) History and hypertension History presented Clinical_event to the Emergency Nonbiological_location Department Nonbiological_location with continuous Detailed_description palpitation Sign_symptom , chest Sign_symptom tightness Sign_symptom , profuse Severity sweating Sign_symptom and nausea Sign_symptom with no obvious predisposing causes Disease_disorder .
The patient experienced a sudden Lab_value drop Lab_value in blood Diagnostic_procedure pressure Diagnostic_procedure and acute Detailed_description confusion Sign_symptom .
After an immediate Detailed_description electrical Therapeutic_procedure conversion Therapeutic_procedure , his consciousness Sign_symptom was gradually restored, and symptoms Sign_symptom relieved.
Then, this patient was transferred Clinical_event to the Department Nonbiological_location of Nonbiological_location Cardiology Nonbiological_location for further evaluations Diagnostic_procedure and treatments Therapeutic_procedure .
The patient's blood Diagnostic_procedure pressure Diagnostic_procedure was 105/75 Lab_value mm Lab_value Hg Lab_value upon admission, with a heart Diagnostic_procedure rate Diagnostic_procedure of 75 Lab_value beats/min Lab_value , body Diagnostic_procedure temperature Diagnostic_procedure of 36.6°C Lab_value and respiration Diagnostic_procedure rate Diagnostic_procedure of 18 Lab_value times/min Lab_value .
The heart Biological_structure border Biological_structure extended Sign_symptom to Lab_value the Lab_value left Lab_value , with the apical Diagnostic_procedure impulse Diagnostic_procedure located in the left Lab_value 5th Lab_value intercostal Lab_value space Lab_value , 1.0 Distance   cm Distance lateral Distance to Distance the Distance midclavicular Distance line Distance .
The patient had a history of hypertension Disease_disorder over History 30 Duration years Duration without History regular History antihypertensive History medication History .
The highest Detailed_description blood Diagnostic_procedure pressure Diagnostic_procedure was 170/110 Lab_value mm Lab_value Hg Lab_value .
There was no Family_history family Family_history history Family_history of Family_history early Family_history coronary Family_history artery Family_history disease Family_history or Family_history sudden Family_history cardiac Family_history death Family_history .
He did History not History smoke Activity cigarettes Activity or History use Activity illicit Activity drugs Activity , and History rarely History consumed Activity alcohol Activity .
He also reported no History known History contacts History with History sick History persons History and History no History recent History travel History .
Twelve Detailed_description - lead Detailed_description surface Detailed_description electrocardiogram Diagnostic_procedure ( ECG Diagnostic_procedure ) of VT Disease_disorder indicated that the origin of VT was at the boundary Biological_structure between Biological_structure right Biological_structure ventricular Biological_structure outflow Biological_structure tract Biological_structure ( RVOT Biological_structure ) and tricuspid Biological_structure valve Biological_structure .
When VT Disease_disorder increased Lab_value to 150 Lab_value beats/min Lab_value or Lab_value higher Lab_value , no epsilon Sign_symptom waves Sign_symptom were found in the precordial Diagnostic_procedure leads Diagnostic_procedure (Figure1A and B).
In contrast, when VT Disease_disorder decreased Lab_value to 120 Lab_value beats/min Lab_value or Lab_value lower Lab_value , epsilon Sign_symptom waves Sign_symptom appeared in leads Diagnostic_procedure V1 Diagnostic_procedure – V2 Diagnostic_procedure (Figure1C).
Notably, the epsilon Sign_symptom waves Sign_symptom preceded Lab_value QRS Lab_value waves Lab_value in leads Diagnostic_procedure V1 Diagnostic_procedure – V2 Diagnostic_procedure , while endocardiac Diagnostic_procedure tracing Diagnostic_procedure confirmed that the corresponding local Lab_value potential Lab_value originating from RVOT Biological_structure appeared prior Detailed_description to Detailed_description the Detailed_description ventricular Detailed_description rhythm Detailed_description (Figure ​(Figure1D).1D).
Sinus Detailed_description ECG Diagnostic_procedure in the year Date of Date 2013 Date suggested a slight Lab_value left Lab_value deviation Lab_value of electric Diagnostic_procedure axis Diagnostic_procedure , with a heart Diagnostic_procedure rate Diagnostic_procedure of 87 Lab_value beats/min Lab_value and flat Lab_value T Lab_value waves Lab_value in lead Diagnostic_procedure II Diagnostic_procedure .
T Sign_symptom wave Sign_symptom inversions Sign_symptom were found in leads Diagnostic_procedure III, Diagnostic_procedure avF Diagnostic_procedure and Diagnostic_procedure V1 Diagnostic_procedure – V3 Diagnostic_procedure , meanwhile epsilon Sign_symptom waves Sign_symptom were found following Lab_value QRS Lab_value complex Lab_value in leads Diagnostic_procedure V1 Diagnostic_procedure – V3 Diagnostic_procedure (Figure ​(Figure2B).2B).
When the lead Diagnostic_procedure avR Diagnostic_procedure was amplified Detailed_description , epsilon Sign_symptom waves Sign_symptom were also found behind Lab_value QRS Lab_value waves Lab_value (Figure ​2C).
Atrial Biological_structure premature Sign_symptom beats Sign_symptom appeared occasionally Frequency .
Moreover, ventricular Biological_structure premature Sign_symptom beats Sign_symptom were also found to originate from the right Biological_structure ventricular Biological_structure apex Biological_structure , with epsilon Sign_symptom waves Sign_symptom appearing behind Lab_value QRS Lab_value waves Lab_value (Figure ​(Figure2B).2B).
In contrast, sinus Biological_structure ECG Diagnostic_procedure obtained in the year Date of Date 1999 Date revealed similar left Lab_value deviation Lab_value of electric Diagnostic_procedure axis Diagnostic_procedure , flat Sign_symptom T Sign_symptom waves Sign_symptom and T Sign_symptom wave Sign_symptom inversions Sign_symptom , but absence of epsilon Sign_symptom waves Sign_symptom (Figure ​(Figure2A).2A).
Data from biochemical Diagnostic_procedure assays Diagnostic_procedure were as follows: cardiac Diagnostic_procedure troponin Diagnostic_procedure I Diagnostic_procedure level was 0.714 Lab_value   μg/L Lab_value (normal range, 0–0.06 μg/L), serum Diagnostic_procedure B Diagnostic_procedure - type Diagnostic_procedure natriuretic Diagnostic_procedure peptide Diagnostic_procedure level was 466.530 Lab_value   pg/mL Lab_value (normal range, 0–100 pg/mL), serum Diagnostic_procedure d Diagnostic_procedure - dimer Diagnostic_procedure level was 8.14 Lab_value   mg/L Lab_value (normal range, 0–0.55 mg/L), blood Diagnostic_procedure urea Diagnostic_procedure level was 11.69 Lab_value   mmol/L Lab_value (normal range, 2.90–7.20 mmol/L), serum Diagnostic_procedure creatinine Diagnostic_procedure level was 144.00 Lab_value   μmol/L Lab_value (normal range, 44–133 μmol/L), serum Diagnostic_procedure uric Diagnostic_procedure acid Diagnostic_procedure level was 611.40 Lab_value   μmol/L Lab_value (normal range, 100–432 μmol/L), and endogenous Diagnostic_procedure creatinine Diagnostic_procedure clearing Diagnostic_procedure value was 57.90 Lab_value   mL/min Lab_value (normal range, >80 mL/min).
Echo Diagnostic_procedure data revealed remarkably Severity enlarged Sign_symptom right Biological_structure atrium Biological_structure and right Biological_structure ventricle Biological_structure , and widened Sign_symptom ROVT Biological_structure .
Uncoordinated Sign_symptom motions Sign_symptom of the left Biological_structure and Biological_structure right Biological_structure ventricular Biological_structure walls Biological_structure were also detected.
Moreover, we also found aortic Biological_structure valve Biological_structure degradation Sign_symptom with slight Severity regurgitation Sign_symptom , slight Severity mitral Biological_structure regurgitation Sign_symptom , and moderate Severity to Severity severe Severity tricuspid Biological_structure regurgitation Sign_symptom .
The left Diagnostic_procedure ventricular Diagnostic_procedure diastolic Diagnostic_procedure function Diagnostic_procedure was reduced Lab_value to 55% Lab_value (Figure ​3A and B).
The coronary Diagnostic_procedure angiogram Diagnostic_procedure revealed no vascular Disease_disorder stenosis Disease_disorder (Figure ​3C–E).
Based on the above-mentioned examinations, this patient met at least 2 major criteria, the bilateral ventricular dilation and the existence of epsilon waves, providing diagnostic support for ARVC Disease_disorder .
A diet Therapeutic_procedure with low Detailed_description salt Detailed_description and low Detailed_description fat Detailed_description was suggested.
The patient was also treated with metoprolol Medication succinate Medication sustained Administration - release Administration tablets Administration ( 23.75 Dosage   mg Dosage daily Dosage , p.o Administration .), amiodarone Medication ( 200 Dosage   mg Dosage daily Dosage , p.o. Administration ), furosemide Medication ( 20 Dosage   mg Dosage daily Dosage , i.v. Administration ), and compound Detailed_description α Medication - ketoacid Medication tablets Administration ( 2.52 Dosage   g Dosage daily Dosage , p.o. Administration ).
Moreover, VTs with different Detailed_description morphologies Detailed_description and Detailed_description cycle Detailed_description lengths Detailed_description were found during radiofrequency Therapeutic_procedure ablation Therapeutic_procedure (Figure 4).
The substrate Diagnostic_procedure voltage Diagnostic_procedure mapping Diagnostic_procedure revealed that the anterior Biological_structure wall Biological_structure of Biological_structure RVOT Biological_structure was wrapped by circular Shape scar Sign_symptom (Figure 5A).
Considering the association of VT with scar areas, substrate Therapeutic_procedure ablation Therapeutic_procedure was chosen for this patient.
The residual potentials in the scar areas were searched, and then linear Detailed_description and focal Detailed_description ablations Therapeutic_procedure were performed (Figure ​5B).
Neither programmed Detailed_description stimulation Diagnostic_procedure nor induced Detailed_description stimulation Diagnostic_procedure could induce VT Disease_disorder after the procedure was completed, indicating the success of operation.
The ECG Diagnostic_procedure after radiofrequency ablation showed sinus Sign_symptom rhythm Sign_symptom , with a heart Diagnostic_procedure rate Diagnostic_procedure of 61 Lab_value beats/min Lab_value , T Sign_symptom wave Sign_symptom inversions Sign_symptom in leads Diagnostic_procedure III Diagnostic_procedure and Diagnostic_procedure avF Diagnostic_procedure , and epsilon Sign_symptom waves Sign_symptom and T Sign_symptom wave Sign_symptom inversions Sign_symptom in leads Diagnostic_procedure V1 Diagnostic_procedure – V3 Diagnostic_procedure (Figure 2D).
This patient was discharged Clinical_event from hospital Nonbiological_location on day Date 9 Date with a regimen of metoprolol Medication succinate Medication sustained Administration - release Administration tablets Administration ( 23.75 Dosage   mg Dosage daily Dosage , p.o. Administration ), amiodarone Medication hydrochloride Medication tablets Administration ( 200 Dosage   mg Dosage daily Dosage , p.o. Administration ), spironolactone Medication tablets Administration ( 40 Dosage   mg Dosage daily Dosage , p.o. Administration ), and fosinopril Medication sodium Medication tablets Administration ( 10 Dosage   mg Dosage daily Dosage , p.o. Administration ).
The patient was followed Clinical_event up Clinical_event 3 Date months Date after Date discharge.
He had no recurrent palpitation Sign_symptom , chest Biological_structure tightness Sign_symptom , profuse Severity sweating Sign_symptom or nausea Sign_symptom .
Although Other_entity ARVC Other_entity was Other_entity the Other_entity main Other_entity diagnosis Other_entity at Other_entity the Other_entity time Other_entity of Other_entity this Other_entity patient's Other_entity initial Other_entity presentation, Other_entity it Other_entity is Other_entity essential Other_entity in Other_entity such Other_entity cases Other_entity to Other_entity perform Other_entity a Other_entity reassessment Other_entity for Other_entity the Other_entity presence Other_entity of Other_entity structural Other_entity heart Other_entity disease, Other_entity which Other_entity can Other_entity evolve Other_entity over Other_entity time Other_entity .