Ventricular Fibrillation in a Patient with Tachycardia-Induced Cardiomyopathy after Liver Transplantation
A 41-year-old man with end-stage liver failure due to hepatitis B virus-associated liver cirrhosis underwent orthotopic liver transplantation (OLT). He had underlying diabetes mellitus and did not have a history of exertional angina, dyspnea on exertion, and paroxysmal palpitations. Preoperative 12-lead electrocardiography showed normal sinus rhythms. Preoperative echocardiographic evaluation showed normal biventricular size and function. Paroxysmal AF with rapid ventricular responses developed on the first postoperative day (; in the online-only Data Supplement). Given the stable vital status with no signs of heart failures or myocardial ischemia, the sinus conversion was not attempted. The patient required a prolonged in-hospital recovery period, during which, continuous renal replacement therapy, mechanical ventilation, and tracheostomy were performed. Flecainide and diltiazem were administered to control recurrent AF after normalization of liver and renal function, 5 weeks after OLT. But, such drugs had to be discontinued after development of congestive heart failures with severe ventricular dysfunction (ejection fraction, 30%) () 9 weeks after OLT. During the hospital stay, the left ventricular ejection fraction increased to 38% after administration of ramipril, carvedilol, and diuretics. The patient was discharged with these medications on top of immunosuppressive drugs including FK 506 and mycofenolate mofetil 11 weeks after OLT. Acute renal failure occurred 3 months after surgery, but resolved after discontinuation of heart failure medications. Repeated echocardiography showed improved left ventricular ejection fraction of 42%.\nSix months after OLT, the patient collapsed while he was walking. The patient was transported to the emergency room under cardiopulmonary resuscitation and ventricular fibrillation was noted on electrocardiogram ( in the online-only Data Supplement). After an immediate defibrillation, AF with rapid ventricular response was noted ( in the online-only Data Supplement). He recovered without neurologic impairments. Coronary angiography showed no significant stenosis. Echocardiography showed severe left ventricular dysfunction with a left ventricular ejection fraction of 21% (). A single-chamber implantable cardioverter-defibrillator (ICD) was implanted. Heart failure treatments, including a β-blocker and an oral anticoagulant, were continued. Ventricular tachycardia with palpitation (cycle length of 290 ms, 18 beats for 5.2 seconds) was detected and terminated by antitachycardia pacing 2 months after the ICD implantation ( in the online-only Data Supplement).\nComplete conversion to sinus rhythm was recorded on ICD after 5-months of alternation between AF and sinus rhythm. Echocardiography showed normalized left ventricular systolic function 8 months after the ICD implantation (). Thereafter, only a β-blocker was administered to prevent tachycardia for 18 months with no recurrences of ventricular arrhythmias.