Case Presentation:
52 year old male with a past medical history of severe coronary artery disease with multiple stents in place and alcohol abuse who initially presented with a 3 day history of chest pain radiating to the neck and left arm. EKG performed in the ER showed a new acute inferior wall ST elevation myocardial infarction. The patient was emergently taken to the cath lab where diffuse, late in‐stent thrombosis and restenosis of his right coronary artery (RCA) stents were found. An aspiration thrombectomy and angioplasty were performed to the RCA with successful return of flow. The patient remained hemodynamically stable and his EKG returned to baseline.
Following transfer out of the CCU, the patient became acutely hypotensive and was found to be in the ventricular tachycardia displayed in Figure 1. The tachycardia was resistant to boluses of amiodarone, lidocaine, IV magnesium, and external shocks. After careful re‐evaluation of the EKG (Fig 1), the potential diagnosis of Belhassen tachycardia was made based on the presence of a wide complex tachycardia with right bundle branch block morphology and left axis deviation. The decision was made to push IV verapamil at this time. After a push of 2.5 mg intravenously, the wide complex tachycardia broke and normal sinus rhythm was restored (Fig 2). Patient’s vital signs improved and pressors were weaned off. Shortly thereafter, the patient returned to a similar appearing rhythm that once again broke with IV verapamil. The patient maintained normal sinus rhythm for the remainder of his hospitalization and was therefore not able to receive an ablative intervention.
Discussion:
Previously described in the literature dating back to 1979, idiopathic left ventricular tachycardia (ILVT) became known as Belhassen VT after Dr. Bernard Bellhassen reported the termination of the arrhythmia following administration of IV verapamil. The diagnosis of ILVT is typically made in patients with no evidence of organic heart disease. The average patient tends to be male, ages 20‐40, who presents with recurrent palpitations that could date back as far as adolescence. The patient described here has long standing coronary artery disease with likely ventricular scarring from previous MIs. While the historic aspects of the case point towards ventricular scar mediated VT (as seen in many post MI patients), several features of the case suggest that this was an atypical post MI arrhythmia. These features include the characteristic EKG findings of PACs preceding a ventricular tachycardia with RBBB morphology and left axis deviation, followed by resolution only with IV verapamil after multiple failed attempts of amiodarione, lidocaine, and external shocks. Ideally, the patient could have been taken to the EP lab during an episode for proper identification and subsequent ablation of this arrhythmia however he remained in NSR throughout the remainder of his hospital course. The clinical dilemma here is that if this were another arrhythmia, such as a supraventricular tachycardia with aberrancy, the effective treatment (verapamil) given here could have resulted in acute worsening of the tachycardia by slowing conduction through the AV node and thus allowing for more conduction to flow throw the aberrant pathway.
Conclusions:
Idiopathic Left Ventricular Tachycardia, also known as Belhassen VT, is typically seen in younger males with no cardiac disease however was potentially identified and treated in an older male with severe CAD and recent NSTEMI with IV verapamil resulting in termination of the rhythm
