The Curious Incident of the Wolff in the Night-time

Author: Craig Douglas, James Thomas / Editor: Craig Douglas, James Thomas / Reviewer: Tadgh Moriarty / Code: A1, CC2, R1Published: 06/08/2020

A man is woken in the night by his dog barking and realises that his previous well 23-year-old girlfriend isn’t breathing. By the time of her arrival in the Emergency Department she has been in VF arrest for over an hour before ROSC.

Her boyfriend reveals that she had recently been diagnosed with sinusitis by her GP and completed courses of metronidazole and olfloxacin. She had also been complaining of intermittent palpitations for the last 6 months but had not sought medical help. There was no suspicion of self-harm or suicidal intent. There was no family history of sudden cardiac death or cardiac disease in the young.

The patient was intubated whilst in cardiac arrest and received care in line with standard UK Resuscitation Council ALS algorithms. ROSC was eventually achieved after more than 60 minutes of resuscitative efforts. The patient began to make spontaneous respiratory effort but remained GCS 3 and tolerant of her ET tube. ABG confirmed good oxygenation and ventilation during post resuscitation care. ECG showed a broad complex rhythm with a prolonged QTc and she maintained a normal blood pressure. Bloods (including potassium, calcium and magnesium) were unremarkable. Bedside ECHO was normal as was CT Head. She developed recurrent runs of pulsed VT and cardiology opinion (SpR on call) was sought due to concerns about using amiodarone given her prolonged QTc. Atenolol was given after this discussion.

She was taken to ITU for continuing post-arrest care. She was extubated successfully; her only complaint being some short term memory loss which slowly improved. Her ECGs were reviewed on ITU by a consultant cardiologist and type B Wolff-Parkinson-White syndrome was provisionally diagnosed. She was transferred to the coronary care unit.

Electrophysiology studies confirmed a right posterior accessory pathway which underwent radiofrequency catheter ablation. ECHO showed significant left ventricular impairment. She was discharged on Ramipril after a 12 day stay.

A month later she was reviewed in Cardiology Clinic. ECHO confirmed that her left ventricular function had returned to normal and ECG showed no pre-excitation evidence. Her Ramipril was stopped and she was deemed cured of Wolff-Parkinson-White.

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