Inappropriate shocks from a transvenous implantable defibrillator caused by atrial fibrillation and a missed atrial septal defect in a patient with a modified Bentall procedure

Figures

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  Figure 1. One of the multiple episodes of atrial fibrillation with a high rate within the ventricular fibrillation zone was treated with implantable cardiac defibrillator shocks. (A) Device programming of two zones of treatment: ventricular tachycardia 176 b.p.m. and ventricular fibrillation 207 b.p.m. (B) The figure is a plot of beat cycles in relation to time. It shows the detection of fast tachycardia that enters the ventricular fibrillation zone and triggers treatment. Burst pacing starts immediately after detection, a first unsuccessful shock at 19.6 Joules follows, and the episode ends with a second successful shock at 34.2 Joules. (C and D) The intracardiac electrocardiograms of the atrial and ventricular lead and the implantable cardiac defibrillator analysis during the episode and the shock. VF, ventricular fibrillation; VT, ventricular tachycardia.

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  Figure 2. Ostial coronary aneurysms on transoesophageal echo and on computed tomography angiography with a gated protocol in the systemic arterial phase. (A) The aneurysms in a short-axis view. (B) A multiplanar reformation of the aneurysms at the anastomosis sites with measurements in two dimensions. The slice thickness of the computed tomography reconstruction was 0.75 mm (B) [scale of original image: (A) 46% and (B) 49%].

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  Figure 3. Coronary aneurysms on computed tomography angiography with a gated protocol in the systemic arterial phase. (A) A volume rendering technique image that clearly illustrates the composite graft and its upper attachment to the distal ascending aorta and the aneurysmatic coronary ‘buttons’ attached to it. The implantable cardiac defibrillator is shown on the top of the figure. (B) A thin-slab maximum intensity projection with measurements of the aneurysms in two dimensions. The slice thickness of the computed tomography reconstruction was 5 mm [scale of original image: (A) 90% and (B) 48%]. ICD, implantable cardiac defibrillator.

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  Figure 4. This image shows the atrial septal defect on echocardiography and computed tomography angiography in the systemic arterial phase. (A) Left to right flow through the atrial septal defect in colour. (B) The colour Doppler of the left to right flow through the atrial septal defect. (C) A four-chamber view of the heart, which shows the dilated right chambers compared to the left due to the overload by the atrial septal defect. (D) The atrial septal defect flow on multiplanar reformation in the end-diastolic phase of the cardiac cycle. The slice thickness of the computed tomography reconstruction was 0.75 mm [scale of original image: (A and B) 28%, (C) 47%, and (B) 49%]. ASD, atrial septal defect; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

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  Figure 5. The Amplatzer device in (A) the transthoracic study four-chamber view and (B) in the transoesophageal study (scale is 50% of the original). LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

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