A Novel, Minimally-Invasive Surgical Approach for Ablation of Ventricular Tachycardia Originating Near the Proximal Left Anterior Descending Coronary Artery

Abstract

Idiopathic ventricular tachycardia (VT) arising from the left ventricular (LV) summit can be challenging for catheter-based percutaneous ablation. We present a patient in whom endocardial and percutaneous epicardial ablations were not successful in eliminating VT. Subsequently, a minimally invasive surgical approach with robotic-assisted mapping, followed by minithoracotomy and cryoablation of the myocardium near the region of the proximal left anterior descending (LAD) coronary artery, was successful in eliminating arrhythmia. A 54-year-old man with a medical history significant for hypertension and sleep apnea presented with exertional palpitations associated with lightheadedness. Holter monitoring revealed frequent premature ventricular contractions (PVCs) and nonsustained VT. β-blockers were started (metoprolol 100 mg BID), but sustained VT was demonstrated on exercise stress testing performed while on β-blockers. Physical examination and laboratory evaluation were unremarkable. Coronary angiography documented normal epicardial coronary vessels with a normal LV ejection fraction (64%). Cardiac magnetic resonance imaging revealed mild LV hypertrophy without fibrosis or other structural abnormalities. Despite optimal dose of β-blockers (metoprolol 100 mg BID) and calcium channel blockers (diltiazem CD 120 mg QD), the patient continued to have symptoms of lightheadedness and presyncope and was subsequently brought to the electrophysiology laboratory for further evaluation and treatment. On 12-lead ECG, the morphology of spontaneous PVCs was predominantly positive in the inferior leads with early precordial transition (V2). The ratio of QS complexes in aVL/aVR was <1, suggestive of origin from the inaccessible region of the LV summit.1 (Figure 1) Figure 1. Surface 12-lead ECG showing premature ventricular contractions with inferior axis, early transition suggesting site of origin near the anterosuperior …