I'm in two hearts about this diagnosis!

A 61-year-old male patient presented to the ED by ambulance following two syncopal episodes. The ambulance crew reported abnormal ECG findings. The patient had felt hot, sweaty, and clammy with palpitations preceding both syncopal events. He had chest and epigastric pain in the past 24 hours. Syncopal events were witnessed by a partner who reported a grey and clammy appearance of the patient. During the A&E review, the patient reported ongoing chest discomfort with no associated symptoms. Previous medical history included a heterotopic heart transplant for myocarditis and long-term oral amiodarone therapy. Examination findings: Pulse: 90bpm; blood pressure: 120/94; SpO2: 98%; RA RR: 18/min Apex beat palpated on the right precordium. Chest: Bilaterally clear with no difficulty in breathing. ECG findings: A sinus rhythm from the transplanted heart was observed in the right-sided leads. Ventricular tachycardia/fibrillation was being picked up from the native heart on the left lateral leads. There is, however, an overlap of these rhythms seen on the ECG. Chest X-ray showed dual cardiac shadows. A Point-of-Care Echocardiogram showed the native heart to be in Ventricular tachycardia/fibrillation with severe systolic dysfunction, and the donor heart in sinus rhythm with good systolic function. The diagnosis was considered to be syncope secondary to an Electrical Storm generated from the native heart. The arrhythmia was being propagated from the native to the donor heart. Patient was started on amiodarone infusion and later transferred to ITU. A transesophageal echocardiogram-guided direct current cardioversion was attempted. After two unsuccessful attempts, a lidocaine infusion was initiated, and a subsequent attempt at DCCV proved successful in restoring the sinus rhythm. The patient was later discharged clinically and hemodynamically stable with oral sotalol and mexiletine. This rare and complex case highlights the importance of ECG interpretation in diagnosing arrhythmias in post-transplant patients.