# Bilateral acute limb ischemia complicating incessant supraventricular arrhythmias in wolff-parkinson-white syndrome: evaluating thromboprophylaxis across multiple cardioversions

## TL;DR

A patient with heart disease and arrhythmia developed severe leg blood clots, highlighting the need for careful anticoagulation decisions in high-risk cases.

## Contribution

Highlights thromboembolic risks in WPW syndrome patients with structural heart disease and frequent cardioversions.

## Key findings

- Incessant SVT with structural heart disease increases thromboembolic risk.
- Delayed anticoagulation can lead to irreversible complications like limb loss.
- Thromboprophylaxis decisions must consider coexisting cardiomyopathy and cardioversion frequency.

## Abstract

Acute limb ischemia (ALI) is a severe complication in patients with structural heart disease and recurrent arrhythmias that often leads to significant morbidity and potential lifelong disability. The combination of arrhythmia, recurrent electrical shocks in patients with incessant supraventricular tachycardia (SVT), and structural heart abnormalities may increase the risk of thrombus formation and migration, raising questions about the role of thromboprophylaxis in such high-risk scenarios.

We present a 54-year-old female with Wolff-Parkinson-White (WPW) Syndrome and structural heart disease who was admitted with incessant SVT, complicated by several episodes of ventricular tachycardia (VT) and ventricular fibrillation (VF). Despite multiple unsynchronized cardioversions, the patient remained hemodynamically unstable. Echocardiography revealed a dilated left ventricle with reduced systolic function and an intracardiac thrombus. During hospitalization, she underwent over ten direct current (DC) shocks, exacerbating her thromboembolic risk. On day three of hospitalization, she developed severe pain in her right leg, progressing to signs of ALI. Doppler ultrasound and CT angiography confirmed thrombi in the abdominal aorta and lower extremities, supporting the diagnose of ALI Rutherford III dextra and ALI Rutherford IIA sinistra. Surgical thrombectomy and anticoagulation were initiated, but ALI progressed, necessitating above-knee amputation in her right leg.

Thromboprophylaxis in patients with structural heart disease and incessant arrhythmia must be carefully assessed. Incessant SVT alone does not justify early anticoagulation, but coexisting cardiomyopathy and repeated cardioversions increase thromboembolic risk. Identifying the underlying cause of structural abnormalities is essential to guide treatment and prevent severe complications. Delayed anticoagulation in the presence of undetected thrombus may result in irreversible events such as limb loss due to ALI.