Recurrent SVT in a Patient With Systemic Amyloidosis

Figure 2: An 82-Year-Old Man With Worsening Exercise Tolerance

Figure 1: An 82-Year-Old Man With Worsening Exercise Tolerance

A 61-year-old Caucasian male with a history of liver transplant for Transthyretin-mediated (TTR) amyloidosis and enteropathy with chronic diarrhea, presented to the emergency room with symptoms of worsening fatigue and shortness of breath. Upon arrival he was noted to be hypotensive with a blood pressure of 71/56mmHg and tachycardic with a heart rate of 165bpm. He denied palpitations, chest pain, PND, or orthopnea. He was treated with one dose of IV adenosine 6mg, which converted the rhythm to sinus with a heart rate of 90. His blood pressure also improved to 90/52. Laboratory data showed a troponin of 0.7ng/mL, potassium of 4.3mg/dl, magnesium of 1.4mg/dl, BUN of 41 and creatinine of 2.2 (baseline creatinine of 1.5). He was diagnosed with acute on chronic renal insufficiency due to volume depletion from chronic diarrhea and admitted to a telemetry floor in the hospital. Over the course of the next few days, electrolytes and volume depletion were corrected and his fatigue and shortness of breath resolved. His acute renal insufficiency improved with creatinine returning to baseline. Interestingly, the patient continued to have runs of tachycardia through his admission that responded to adenosine. A 2-D echocardiogram was performed and showed left ventricular ejection fraction of 55%, mild concentric left ventricular hypertrophy, Left atrial dimension of 4.3cm, and normal right ventricular function. There was no evidence of valvular disease. A cardiac MRI showed left ventricular ejection fraction of 56%, focal regions of increased myocardial wall thickness with associated late gadolinium enhancement (LGE) and wall motion abnormalities noted to involve the basal and mid septum and basal inferior and basal inferolateral walls.

What would be the next most appropriate course of action?

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