History
A 69-year-old man had underlying complete heart block and chronic atrial fibrillation, diabetes mellitus, and hypertension. He had a single-chamber pacemaker implanted in 2003 for complete heart block. He developed ventricular tachycardia 8 years previously, which required cardioversion. He was referred for further management.
Current Medications
The patient was taking bisoprolol 5 mg daily, atorvastatin 10 mg daily, perindopril 4 mg daily, warfarin 2 mg daily, and subcutaneous insulin injection. Mixtard 48 units in the morning and 20 units at night.
Current Symptoms
The patient was breathless on moderate exertion.
Physical Examination
Laboratory Data
Electrocardiogram
Findings
Figure 12-1 shows the electrocardiogram (ECG) of the patient before admission to the casualty unit. Figure 12-2 shows the ECG of ventricular tachycardia on admission to the casualty unit.
Catheterization
Findings
The coronary angiogram showed mild coronary artery disease. A plan for conservative management was defined.
Focused Clinical Questions and Discussion Points
Question
What is the anatomic basis of mapping the coronary sinus for location of a phrenic-free stimulation site?
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