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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 89-92

An interesting case of unusual cause of refractory ventricular tachycardia in a chronic kidney disease patient


1 Department of Cardiology, Yashoda Hospitals, Malakpet, Hyderabad, Telangana, India
2 Department of Nephrology, Yashoda Hospitals, Malakpet, Hyderabad, Telangana, India
3 Department of Vascular Surgery, Yashoda Hospitals, Malakpet, Hyderabad, Telangana, India

Date of Submission04-Nov-2020
Date of Acceptance26-Nov-2020
Date of Web Publication03-May-2021

Correspondence Address:
Dr. Ashwin Tumkur
Yashoda Hospitals, Nalgonda X Roads, Malakpet, Hyderabad - 500 036, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicc.jicc_78_20

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  Abstract 


Refractory ventricular tachycardia (RVT) has been a life-threatening form of arrhythmias. There are many causes reported in literature that are found to trigger RVT. Here, we report a rare cause of RVT. A gentleman under maintenance hemodialysis since 1 year was emplaced with permacatheter since then. He presented with signs and symptoms of RVT, on evaluation, it was found that RVT was caused due to broken permacatheter fragment that was embolized into the right ventricle. It was successfully retrieved through snare loop as an emergency and the RVT was then reverted to normal rhythm. Therefore, in patients undergoing hemodialysis or under treatment with such access devices symptoms of chest pain, irregular heart rhythms or complications like retained catheter must be considered as a part of differential diagnosis, even when substantial time has elapsed after initial catheter access emplacement.

Keywords: Chronic kidney disease, hemodialysis, permacatheter, snare, ventricular tachycardia


How to cite this article:
Tumkur A, Sudhakar G, Goura P. An interesting case of unusual cause of refractory ventricular tachycardia in a chronic kidney disease patient. J Indian coll cardiol 2021;11:89-92

How to cite this URL:
Tumkur A, Sudhakar G, Goura P. An interesting case of unusual cause of refractory ventricular tachycardia in a chronic kidney disease patient. J Indian coll cardiol [serial online] 2021 [cited 2021 Sep 18];11:89-92. Available from: https://www.joicc.org/text.asp?2021/11/2/96/315267




  Introduction Top


Refractory ventricular tachycardia (RVT) is a form of ventricular tachycardia (VT) emerging as at least more than two separate episodes of VT that would mandate intervention within 24 h of onset.[1] The incidence of VT is rare and mortality due to this accounts for about 50% of deaths that have been related to cardiac causes.[2] However, RVT is a rarer form of VT but has been related to poorer outcomes.

There have been myriad causes for RVT such as ischemia, heart failure, systemic illness, renal failure, certain mineral/ionic imbalances, proarrhythmic medications, increased catecholamine levels, and a culprit lesion in coronaries. At times, the cause of RVT presentation remains idiopathic. The management of RVT is entirely based on the underlying cause. It has been stated in literature that about 25% patients with RVT have reversible causes.[3] Therefore, identifying and addressing the cause itself can become the key to its successful management. Here, we present a case of RVT that holds an unusual cause of its presentation and on its proper diagnosis and removal the condition of RVT had reverted.


  Case Report Top


A 49-year-old man was referred to our department of cardiology with RVT. He presented to emergency room with complaints of dizziness, chest discomfort, and dyspnea since 3 h. He had received multiple antiarrhythmic medications including injection cordarone in previous hospital. On evaluation, electrocardiogram was still showing persisting WQRS tachycardia suggesting refractory monomorphic VT [Figure 1]a. Echocardiographic screening showed mild left ventricular dysfunction. He was immediately DC verted with 200 J shock to normal sinus rhythm. History further revealed that he was a known case of chronic kidney disease on maintenance hemodialysis (MHD) since more than a year. Other comorbidities were hypertension, old cerebrovascular accident, and chronic liver disease and was on regular follow-up. As a hospital protocol (all patients requiring admission are subjected to computed tomography [CT] lungs screening in the COVID pandemic), high resolution CT was done which surprisingly revealed a catheter lying across right atrium (RA)-right ventricle (RV) [Figure 1]b. The Chest X-ray (CXR) also showed a long tube-like radio opaque foreign body over right heart shadow [Figure 1]c. Initial laboratory investigations revealed serum creatinine level of 11.5 mg/dl, Hb was 8.3 g%, serum Sodium was 137 mmol/dl, and serum potassium was 6.9 mmol/dl. On further enquiring, the relatives revealed that about 3 months back in other hospital, doctors did a procedure on him to remove the catheter which they had inserted a year back that was used for dialysis. They were also told that the part of catheter could not be retrieved and was sutured under the skin. However, they continued dialysis using brachiocephalic arterial venous fistula in the left hand. With this information from patient relatives, we suspected the catheter to be permacatheter, and the embolized and retained permacatheter into RA-RV was the cause for his life-threatening VT.
Figure 1: (a) Electrocardiogram at presentation showing ventricular tachycardia, DC verted to SR; (b) Computed tomography image showing the permacatheter lying in right atrium-right ventricle cavity; (c) Chest X-ray showing tube-like radio opaque foreign body over right heart shadow

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We planned for an emergency retrieval of the retained permacatheter, as it could anytime precipitate VT again. After counseling attenders, he was taken to cath lab and under Fluoro imaging the fractured part of permacatheter was caught into snare at superior vena cava (SVC)-RA junction. It was successfully retrieved by snaring it out through right femoral vein access [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e. However, the catheter had slipped off at femoral level [Figure 2]f, we had to snare it again and get it out after femoral vein cut down [Figure 3]. The patient tolerated the procedure well. Later, dialysis was done post procedure. Tip of retrieved permacatheter was sent for culture, which showed negative for any growth. He had no further episodes of VT, and was discharged 2 days later in hemodynamically stable condition. At discharge, serum creatinine level was 6.4 mg/dl. He is on follow-up since the past 10 months, doing well on MHD and free of arrhythmias. Successful snare retrieval of broken embolized permacatheter from RA-RV was done in this rare and interesting case of refractory VT.
Figure 2: (a) Angiogram depicting attempt to snare catheter; (b) Snaring the catheter through right femoral vein access; (c-e) Snared catheter being pulled down; (f) Catheter slipped off the snare at femoral level, snared again successfully

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Figure 3: (a) Image of catheter being pulled out after femoral vein cut down; (b) Retrieved permacatheter

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  Discussion Top


At many incidents, need mandates to emplace central or peripheral catheters in veins proximal to cardiopulmonary system for the administration of drugs, blood products, fluid and parenteral nutrition, etc.,[4] These intravenous access devices usually stay for many years in patient's body. Owing to longer periods, rarely these might substantiate some complications such as catheter malposition, migration, obstruction, infection, thrombosis, and catheter fracture.[5] Fractured catheter segments may cause complications in near or later future, therefore its removal out of body could be a better option. Surgical and percutaneous methods could be applied for removal. Of these percutaneous retrieval is considered as the gold standard treatment because of its minimal invasiveness, simple procedure, and low complication rates as compared to surgical treatment.[6],[7] The fractured catheter at times gets migrated along with the blood stream and get embolized into cardiopulmonary system; such as in the SVC, the RA, the RV, the main pulmonary artery or its branches. Often clinical signs such as arrhythmia, pulmonary embolism, septic syndromes, myocardial injuries, hemoptysis, thrombosis, and perforation have been noticed due to the catheter fragments.[8],[9] However, the fractured segments may also remain asymptomatic or lead to only modest symptoms. Yousefshahi et al. reported case of a 50 years old female, who had a history of breast cancer, so had underwent permacatheter emplacement in the right subclavian vein for chemotherapy. In a routine follow-up, her CXR investigation demonstrated embolized fragment of permacatheter lying between RV and left pulmonary artery, 3 years after its initial insertion. However, there were no signs and symptoms of embolization or any chief complaint pertaining to it. Therefore, it was decided to leave catheter fragment in its position, and the patient was advised to undergo regular follow-ups.[9] Similarly Teoh et al. also reported a case of 2-year-boy who was under chronic hemodialysis and therefore a tunneled hemodialysis catheter was inserted. On routine follow-up, the catheter was found to be fractured with a part of it been embolized into a branch of the left pulmonary artery. However, the patient was asymptomatic and the catheter part was removed successfully using loop snare device, through right femoral access.[10]

In this case, the patient presented with symptoms of RVT due to embolization of catheter fragment into RV and therefore the embolized fragment was decided to be removed through the loop snare and after removal, the patient condition was stabilized with no further recurrence of VT. However, occasionally, the intact catheters or the embolization of catheter fragments into cardiopulmonary system may trigger signs and symptoms not directly relevant to the place of embolization. Like in a case reported by Kumar et al., the permacatheter was intact in its actual position when it triggered the symptom of fever. A 25-year-old female was on hemodialysis since 3 years and a permacath was implanted 3 months back. She presented with complaint of fever since 2 weeks. Upon detailed investigation, no other cause of fever was suspected. Therefore, it was decided to remove the permacatheter from the body. While removing it, a part got fractured and embolized with its one end in RV and another in jugular vein. The EP ablation catheter and snare were used for successful removal of catheter fragment from the body.[11] In another case documented by Assis et al., an old female with end-stage kidney failure and had been inserted with tunneled hemodialysis catheter 5 months ago for treatment, which was now found obstructed. Therefore, deep arteriovenous fistula was punctured on her left arm, during puncturing the patient complained of sudden onset of left inframammary pleuritic pain. Upon examination, it was found that a fragment of tunneled catheter was migrated into RV and was perforating RV anterior wall into the pericardial cavity with a loculated pericardial effusion. It was thereby removed surgically.[12]

Rarely, unusual signs and symptoms leading to late diagnosis of such catheter displacements may also lead to death. Banerjee et al. had reported a case of atrial perforation due to permacatheter fragment which was presented as retrosternal chest pain and shortness of breath. The actual cause of this presentation was not diagnosed timely and the patient died. Upon postmortem, it was found that right atrial wall was eroded by one arm of the permacatheter that had caused contusion of the overlying pericardium. Catheter had also caused atrial muscle necrosis.[13]

To the best of our knowledge, this is the first case in which patient presented with permacatheter fragment embolization as RVT, who was timely diagnosed and managed by snaring out the retained catheter from RA-RV. Till now no such case has been reported in literature where a retained, embolized permacatheter was retrieved by percutaneous snaring from the right heart chambers in a chronic kidney disease patient presenting with life threatening refractory VT. Thus, in patients undergoing hemodialysis with such access devices, chest pain, irregular heart rhythms, or complications like retained catheter must be considered as a part of differential diagnosis, even when substantial time has elapsed after initial catheter access emplacement.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, Camm AJ, Borggrefe M, Buxton AE, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for practice guidelines (writing committee to develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death). J Am Coll Cardiol 2006;48:e247-346.  Back to cited text no. 1
    
2.
McNally B, Robb R, Mehta M, Vellano K, Valderrama AL, Yoon PW, et al. Out-of-hospital cardiac arrest surveillance-Cardiac arrest registry to enhance survival (CARES), United States, October 1, 2005-December 31, 2010. MMWR Surveill Summ 2011;60:1-9.  Back to cited text no. 2
    
3.
Hohnloser SH, Al-Khalidi HR, Pratt CM, Brum JM, Tatla DS, Tchou P, et al. Electrical storm in patients with an implantable defibrillator: Incidence, features, and preventive therapy: Insights from a randomized trial. Eur Heart J 2006;27:3027-32.  Back to cited text no. 3
    
4.
Clay TD. Pinch-off syndrome: A simple test is the best. Intern Emerg Med 2012;7:S141-3.  Back to cited text no. 4
    
5.
Peng J, Zhang XM, Yang L, Xu H, Miao ND, Ren YJ, et al. A novel two-step technique for retrieving fractured peripherally inserted central catheter segments migrating into the heart or the pulmonary Artery. Biomed Res Int 2016;2016:7814529.  Back to cited text no. 5
    
6.
Motta Leal Filho JM, Carnevale FC, Nasser F, Santos AC, Sousa Junior Wde O, Zurstrassen CE, et al. Endovascular techniques and procedures, methods for removal of intravascular foreign bodies. Rev Bras Cir Cardiovasc 2010;25:202-8.  Back to cited text no. 6
    
7.
Sheth R, Someshwar V, Warawdekar G. Percutaneous retrieval of misplaced intravascular foreign objects with the Dormia basket: An effective solution. Cardiovasc Intervent Radiol 2007;30:48-53.  Back to cited text no. 7
    
8.
Surov A, Wienke A, Carter JM, Stoevesandt D, Behrmann C, Spielmann RP, et al. Intravascular embolization of venous catheter–causes, clinical signs, and management: A systematic review. J Parenter Enteral Nutr 2009;33:677-85.  Back to cited text no. 8
    
9.
Yousefshahi H, Bina P, Yousefshahi F. Permcath catheter embolization: A case report. Anesth Pain Med 2015;5:e17978.  Back to cited text no. 9
    
10.
Teoh CW, Thakor AS, Amaral JG, Parra DA, Harvey EA, Noone DG. Successful image-guided retrieval of an embolized fragment of a fractured haemodialysis catheter tip from the pulmonary artery. Case Rep Nephrol Dial 2016;6:21-5.  Back to cited text no. 10
    
11.
Kumar D, Banerjee S, Naik J, Gupta K, Roy RR, Kumar A. A novel use of EP catheter in extraction of trapped intracardiac devices: Two case reports. Indian Heart J 2015;67:S92-6.  Back to cited text no. 11
    
12.
Assis LV, Pereira ER, Sá CB, Guimarães-Neto I, Masson-Silva JB, Matos TO, et al. Right ventricular perforation by tunneled hemodialysis catheter. Kidney Int 2017;91:255.  Back to cited text no. 12
    
13.
Banerjee A, Bhowmick K, Nayagam M, Farrington K. Late atrial perforation from tunnelled haemodialysis catheter. QJM 2010;103:527-9.  Back to cited text no. 13
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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