Abstract 20180: Erroneous Diagnosis of Brugada Syndrome: Advanced Multi-Modality Coronary Evaluation to Establish an Ischemic Etiology for Recurrent Ventricular Arrhythmia

Introduction: Rapid diagnosis of ST-segment elevation (STE) myocardial infarction is mandatory for optimal treatment, but standard coronary angiography may occasionally result in misdiagnosis. Case presentation: A 54-year-old man was referred for second opinion on treatment of recurrent ventricular tachycardia (VT) and chest pain. Three years prior, he suffered a cardiac arrest requiring AED shock. Initial EKG showed 5-10 mm STE in leads V2-V6. Emergent coronary angiography at another facility reportedly showed non-obstructive disease, and STE resolved spontaneously. Procainamide challenge during a subsequent electrophysiology study elicited changes diagnosed as Brugada syndrome, and an ICD was implanted. Over the next several years, he had frequent episodes of VT, often associated with chest pain and terminated with anti-tachycardia pacing. Multiple antiarrhythmic drugs were ineffective, and VT ablation was recommended. Based on the history and original EKG, we proceeded with multi-modality coronary evaluation and provocative testing for coronary vasospasm. An indistinct proximal LAD lesion was further evaluated with fractional flow reserve (FFR) testing, showing a baseline FFR of 0.90 that decreased to 0.67 after administration of intracoronary adenosine. Optical coherence tomography (OCT) revealed 90% eccentric ostial LAD stenosis (see Figure). Given the location and severity of the lesion, he underwent successful robotic totally endoscopic beating heart LIMA-LAD bypass grafting. Post-operatively, both chest pain and episodes of VT resolved. Conclusions: The differential diagnosis of transient STE includes several non-coronary etiologies. However, in the setting of dramatic STE across the precordium and recurrent ventricular arrhythmias, a comprehensive, multi-modality coronary evaluation should be employed to identify lesions that may be otherwise equivocal via angiography or sites of significant vasospasm.