Recurrent Supraventricular Tachycardia in a Patient with Heart Transplant

IdentificationFemale patient, 58 years old. Clinical historyThe patient had a history of acute myocardial infarction in 1992; after the event, she developed heart failure with reduced ejection fraction (35%), New York Heart Association (NYHA) functional class II.She reported no other comorbidities and denied smoking and alcoholism.She was being treated with carvedilol 12.5 mg twice daily, enalapril 10 mg twice daily, simvastatin 20 mg, acetylsalicylic acid 100 mg , furosemide 40 mg , and spironolactone 25 mg once daily.In April 2015, she was hospitalized for an episode of monomorphic ventricular tachycardia (VT) with a heart rate (HR) of 170 bpm, blood pressure of 93/52 mmHg , and persistent chest pain, characterizing unstable VT.She underwent synchronized electrical cardioversion at a 200 J charge, with reversion to sinus rhythm.During the same hospitalization, she was started on amiodarone and underwent implantation of a single-chamber cardioverter-defibrillator.During outpatient follow-up after cardioverter-defibrillator implantation, she presented recurrent episodes of slow VT, with HR of 100 to 110 bpm (Figure 1).The VT episodes were interrupted by antitachycardia cardioverter-defibrillator pacing.In April 2016, she was referred for VT ablation.During the procedure, an extensive area of fibrosis was identified in the apical region of the left ventricle.During ventricular pacing, the induction of 3 different VT morphologies was observed, with HR of 110 bpm, without hemodynamic instability.Radiofrequency ablation was performed based on entrainment and pace mapping.No attempt was made to induce VT at the end of the procedure.After ablation, while using carvedilol 12.5 mg twice daily and amiodarone 200 mg once daily, the patient continued