<HTML><BODY style="word-wrap: break-word; -khtml-nbsp-mode: space; -khtml-line-break: after-white-space; "><DIV><FONT class="Apple-style-span" face="Arial">Reversible Causes of VT/VF: Fact or Fiction? Case presentation and review of the literature</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">G. D. Veenhuyzen, MD</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">D. George Wyse, MD, PhD</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">Dr. Serge Boveda (France)</FONT></DIV><DIV><DIV><DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">- Your case report clearly shows that transient causes are more likely to occur in patients suffering from severe heart disease: most of the time they should be implanted with an ICD for primary prevention. Don’t you think that guidelines concerning ICD implantation among patients with VT/VF due to transient or reversible disorders should mainly concern patients with no (or mild) structural heart disease?</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">Dr. George Veenhuyzen and George Wyse (Canada)</FONT></DIV></DIV><DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">- The current guidelines do not advise an ICD for VT/VF with transient or reversible causes but are slilent on the issue of co-existing heart disease. It is true our case had extensive heart disease and it may be true such patients are more likely to have recurrence of the so-called transient or reversible cause as the substrate for arrhythmia continues to exist. The difficulties are twofold. First, in patients with other conditions such as renal and lung disease, the transient or correctable causes (electrolyte abnormalities and hypoxemia) continue to recurr unpredicatably. Second, it is difficult to be sure there is not a continued substrate. For example, in a patient rescued from drowning and found to have VF, it may later be difficult to exclude long QT syndrome. Thus, as stated in our paper, it requires a great deal of clinical judgment to determine if VT/VF had a truly tansient or correctable cause and is unlikely to recur. I do not think there will ever be a simple set of rules or conditions that replace clinical judgment and would favor a guideline that is more permissive in this area.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">Dr. Serge Boveda (France)</FONT></DIV><DIV><DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">- Concerning the “trigger” of VT/VF, do you think that successful ablation of the “triggering VPB’s” (as demonstrated by Michel Haïssaguerre for Purkinje or Brugada patients…) should be considered as a reversible cause and by the way, avoid ICD implantation in patients with no (or mild) structural heart disease?</FONT></DIV></DIV><DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">Dr. George Veenhuyzen (Canada)</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">- I think it is too early to tell if ablating "triggering" VPBs will be complete treatment and in which cases. So far there has been few reports in relatively selected patients. Brugada and other channelopathies are a rather small number of VT/VF cases. The thing about VPBs are they are rather ubquitous, like weeds in your garden. When you remove one it is soon replaced by another. Thus, I am doubtful at the moment that this would be a complete solution in many patients.</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">Dr. Serge Boveda (France)</FONT></DIV><DIV><DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">- Regarding with literature data, how long would you consider that VT/VF is a transient or reversible cause after an acute myocardial ischemia?</FONT></DIV></DIV><DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">Dr. George Veenhuyzen (Canada)</FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">- I think ischemia is a truly reversible cause mostly in the absence of scar (previous infarction) until a defintive treatment like revascularization is applied. The best example is vasospastic angina that causes VT/VF in an otherwise normal heart. Good medical therapy (two or more vasodilators and a statin) can be effective treatment. </FONT></DIV><DIV class="MsoNormal"><FONT class="Apple-style-span" face="Arial">I have a few such cases with defibrillators who have never had a therapy from there ICD in over 10 years. However, it is important to remember that ischemia can return in the case of atherosclerotic disease due to progression of disease or incomplete revascularization.</FONT></DIV></DIV></DIV></DIV></DIV></DIV></DIV></DIV><BR><BR><DIV> <SPAN class="Apple-style-span" style="border-collapse: separate; border-spacing: 0px 0px; color: rgb(0, 0, 0); font-family: Helvetica; font-size: 12px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; text-align: auto; -khtml-text-decorations-in-effect: none; text-indent: 0px; -apple-text-size-adjust: auto; text-transform: none; orphans: 2; white-space: normal; widows: 2; word-spacing: 0px; "><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">--</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dr.<SPAN class="Apple-converted-space"> </SPAN>Sergio<SPAN class="Apple-converted-space"> </SPAN>Dubner</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">President<SPAN class="Apple-converted-space"> </SPAN>of<SPAN class="Apple-converted-space"> </SPAN>Scientific<SPAN class="Apple-converted-space"> </SPAN>Committee</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal Lucida Grande; min-height: 16px; ; font-family: Lucida Grande; font-size: 13px; "><BR style="font-family: Lucida Grande; font-size: 13px; "></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dr.<SPAN class="Apple-converted-space"> </SPAN>Edgardo<SPAN class="Apple-converted-space"> </SPAN>Schapachnik</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">President<SPAN class="Apple-converted-space"> </SPAN>of<SPAN class="Apple-converted-space"> </SPAN>Steering<SPAN class="Apple-converted-space"> </SPAN>Committee</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV><BR class="khtml-block-placeholder"></DIV><BR class="Apple-interchange-newline"></SPAN> </DIV><BR></BODY></HTML>