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KMID : 1011920130140040026
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International Journal of Arrhythmia
2013 Volume.14 No. 4 p.26 ~ p.33
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Ablation of Ventricular Tachycardias With Left Ventricular Apical Endocardial and Epicardial Exit Sites in a Patient With Nonischemic Cardiomyopathy
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Lee Man-Young
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Abstract
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In this report, we describe a case of ventricular tachycardia (VT) ablation performed in a patient with an implantable cardioverter defibrillator (ICD) and recurrent VTs with different morphologies and 2 exits, one from the endocardium and another from the epicardium. A 76-year-old woman with a history of congestive heart failure and with moderate to severe aortic insufficiency had recurrent VT, which became incessant. The patient had received ICD implantation 3 years ago. The problematic VT exhibited a right bundle branch block (RBBB) configuration and superior axis deviation. Two different VT morphologies were seen during programmed right ventricular (RV) stimulation. The first VT was very similar to the clinically documented VT while the second showed a wider QRS complex compared to the first VT. After creating a 3-dimensional voltage map of the left ventricle (LV), we performed pace-mapping along the border zone where multiple isolated delayed potentials were recorded between the low and normal voltage areas. The sites showed well-matched pace-maps gathered in the apical region, where we deployed a linear ablation lesion along the border zone. After endocardial linear ablation, the first VT was not re-induced, but the second VT, which was suspected to exit from the epicardium, was sustained. We placed an irrigating ablation catheter in the apical area facing the endocardial ablation lesion by transcutaneous pericardial puncture. We identified an ablation site that showed an M-shaped local electrogram (EGM) spanning the diastolic interval of the second VT. However, entrainment mapping was not possible at that site due to pacing inability. We attempted ablation based on thermal mapping. Within 7.0 seconds of radiofrequency (RF) energy application at that site, the VT was terminated. The patient continues to be in a stable condition at this time, approximately 6 months following the procedure.
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KEYWORD
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endocardium , epicardium , nonischemic cardiomyopathy , RF ablation , ventricular
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