(190) When Time Stands Still: Cardiac Arrest Revealing ARVC in an Elderly Patient

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic condition characterized by fibrotic replacement of the right ventricular myocardium. It often presents in younger patients and athletes as fatal ventricular arrhythmias. We report a case of suspected ARVC presenting with cardiac arrest due to ventricular tachycardia (VT) at age 60.

Description: A 63-year-old patient with history of hypertension and dyslipidemia presented to the emergency department for cardiac arrest. Patient was in his usual state of health when he suddenly collapsed and lost consciousness. EMS was called and patient underwent more than half an hour of cardiopulmonary resuscitation. His arrest was characterized by intermittent periods of VT and pulseless electrical activity, requiring multiple defibrillations. After ROSC, patient had returned to his baseline mental status, following commands and answering questions appropriately. Post-arrest EKG demonstrated right bundle branch morphology and pathologic Q-waves to II, III, and aVF, without any T-wave inversions. CT Head was negative for any intracranial abnormality. CTA chest was negative for any pulmonary embolism. Transthoracic echocardiography demonstrated an enlarged right ventricle (RV) with moderately decreased RV systolic function, and possible RV free wall aneurysm, raising concerns for ARVC. Cardiac MRI demonstrated scar present in the mid inferior and mid inferolateral walls in a non-ischemic pattern and focal RV akinesis (meeting one major criterion of the 2020 International Criteria for the diagnosis of ARVC). Upon further questioning, patient reported multiple family members who had required ICD/pacemaker placement for cardiac problems. Patient underwent ICD placement for secondary prevention and was discharged home with close outpatient follow up for probable ARVC.

Discussion: ARVC is typically seen in younger individuals presenting with VT arrest and sudden cardiac death. Later presentations are extremely rare and likely reflect genetic mutations with milder phenotypic changes to the myocardium. Our case reflects the need for further genetic characterization of familial ARVCs.