Case Report IICRT implantation with coronary sinus dissectionA case of intractable ventricular tachycardia in a patient on haemodialysisA man with three rhythmsAcute intoxication by flecainide in childhood: case reportFocal PAC arising from RSPV initiating episodes of AF

# CRT implantation with coronary sinus dissection {#article-title-2} Objective Should CRT implantation proceed after CS dissection? Methods We reported an 84-year-old lady who had class III–IV heart failure attacks due to atrial fibrillation (AF) for the past year. She had tachybradycardia for her AF. Electrocardiogram showed borderline QRS interval prolongation for 110 ms. Amiodarone was given but was taken off because of bradycardia. A CRT-P was tried to implant. However, coronary sinus angiogram showed only one small lateral vein. The procedure was also complicated with CS dissection. Finally, the dissection part was negotiated and a 4F LV lead was implanted. Results The lady enjoyed a symptom-free period after the CRT-P implantation. Conclusion CS dissection was common in CRT implantation and process could be continued if haemodynamic status was stable. # A case of intractable ventricular tachycardia in a patient on haemodialysis {#article-title-3} A 55-year-old female was referred to our hospital complaining appetite loss and general malaise. She had 1-year history of haemodialysis due to autosomal-dominant polycystic kidney disease and was taking 100 mg of flecainide daily for paroxysmal atrial fibrillation. She lost consciousness while waiting for consultation. Electrocardiogram at that time showed ventricular tachycardia (VT) with very wide sine curve like QRS. Gradually VT became uncontrollable and she fallen cardiac arrest after direct current cardioversion followed by resuscitation. Mechanical ventilation with deep sedation and continuous infusion of epinephrine and lidocaine were done together with continuous haemodiafiltration. Serum concentration of flecainide was up to 1492 µg/L (effective range 200–1000) on admission and it got lower gradually. QRS duration in sinus rhythm decreased from 186 to 102 ms and VT was not seen anymore. We performed an electrophysiological study after finishing intensive care, but VT was not induced with double extra stimuli of two sites in right ventricle. Her complaints of appetite loss and general malaise were disappeared at that time, and we assessed that those symptoms were also derived from flecainide intoxication. We learned lessons from this case that it must be very careful to treat atrial fibrillation in patient with haemodialysis especially in very small patient (145.0 cm, 38.6 kg this case) and serum concentration of antiarhythmic agent should be monitored periodically. Furthermore, in case of VT by drug intoxication, treatment should be continued even when VT is very intractable because it is curable after intoxication become well. # A man with three rhythms {#article-title-4} Background and objective ICD troubleshooting is a frequently encountered clinical issue. This case report tries to illustrate the diagnostic and management strategies in ICD patients who experience multiple device therapies. Method Case report. Result Mr Wong is a 61-year-old gentleman with history of hypertension, obstructive sleep apnoea, and non-ischaemic dilated cardiomyopathy. His baseline left ventricular ejection fraction was 35%. Coronary angiogram in March 2010 showed only minor disease. Medtronic Maximo DR dual-chamber ICD was implanted in May 2011 for primary prevention of sudden cardiac death. He remained well till October 2011 when he experienced multiple ICD shocks. He had no chest pain or syncope. ICD interrogation revealed multiple runs of tachycardia treated with anti-tachycardia pacing and ICD shocks. Detailed revision of EGM tracings revealed underlying atrial fibrillation and three different ventricular EGM morphologies. The patient was treated with amiodarone and beta-blocker. ICD diagnostic and programming strategies were reviewed. Conclusion This case illustrated the importance of ICD troubleshooting, management of appropriate and inappropriate ICD therapies, and strategic programming in reducing inappropriate therapies. # Acute intoxication by flecainide in childhood: case report {#article-title-5} Background Flecainide is a class Ic anti-arrhythmic drug with sodium-channel blocking activities. Overdose is very uncommon, its management is difficult, and mortality is high. Objective To describe a case of flecainide intoxication in a child and the effectiveness of hypertonic sodium bicarbonate as antidote in flecainide overdose. Case summary A 2-year-old male child with history of orthodromic reciprocating tachycardia had been receiving flecainide 5 mg/kg/day. The patient was carried into our Intensive Care Unit after intake of 1 g of flecainide by himself, he was bradicardic, and the surface electrocardiogram showed a prolongation of QTc interval, atrioventricular dissociation, and wide QRS complex. He was treated with high dose of hypertonic sodium bicarbonate and isoproterenol; a monomorphic ventricular tachycardia triggered without haemodynamic instability which disappeared after bolus administration of intravenous amiodarone. After 12 h of treatment, the patient recovered synusrhythm and 5 days later he was discharged from hospital. Conclusion Our observations suggest that hypertonic sodium bicarbonate is effective to the treatment of flecainide intoxication in childhood. # Focal PAC arising from RSPV initiating episodes of AF {#article-title-6} A 55-year-old male, hypertensive from past 5 years, complains of episodic palpitations from 2 years. He would get very uncomfortable during palpitations. The symptoms from last 7 months occurred 8–10 times in a day. He was diagnosed as paroxysmal AF and tried on medical therapy with no change in symptoms. He was referred for AF ablation. ECG during symptoms showed AT with atrial rate of 220 bpm positive p-waves in V1, II, III, aVF, and VR of 130–150 bpm. Two-dimensional Echo/TEE was normal. He was taken up for RF ablation by 3D mapping with Ensite. A decapolar catheter was placed in CS and a Halo catheter was placed in RA. Tachycardia came spontaneously. It was seen as a recurring phenomenon that a PAC was initiating episodes of slow atrial fibrillation. The earliest atrial activation during the PAC was seen in Halo 13-14, which corresponded to SVC-RA junction. Correlating the anatomical origin, a diagnosis of PAC arising from RSPV was made. Using the trans-septal route, mapping was done in the pulmonary veins. Early electrograms were seen in the ablation catheter in the RSPV. Two RF pulses were given at this site during tachycardia which broke during the pulse. No spontaneous tachycardia was seen post ablation. No burst of PV activity or sustained AF was seen. Stimulation protocol (baseline and post isoprenaline) was done post ablation and no tachycardia was inducible. A 24 h Holter monitoring done at 12 months was normal. This phenomenon has been described post PV isolation but not otherwise.