Recurrent Episodes Of Ventricular Tachycardia Research Articles

SYMPATHETIC DENERVATION OF STELLATE GANGLION FOR MANAGEMENT OF PERSISTENT VENTRICULAR TACHYCARDIA: A CASE REPORT

This case report presents the effectiveness of stellate gan­glion ablation for the control of persistent ventricular tachycardia (VT) resistant to standard therapies. A male patient in his 60s with a history of ischemic cardiomyo­pathy, implanted cardioverter-defibrillator (ICD), and recent coronary angioplasty experienced multiple daily recurrent VT episodes. Runs of low-rate VT episodes persisted despite extensive medical and interventional efforts. Unlike previous procedures, blockade of stellate ganglion and consequent thoracoscopic stellate ganglion ablation resulted in complete suppression of arrhythmia. The report highlights the promising outcomes of a holis­tic approach involving explorative percutaneous stellate ganglion blockade and consequent ablation of stellate ganglion for sympathetic denervation, offering potential improvement in challenging clinical scenarios.

Chronic myocarditis as a cause of recurrent episodes of ventricular tachycardia and dilated cardiomyopathy requiring heart transplantation: a case report

We present a clinical description of a patient with recurrent resistant episodes of ventricular tachycardia that first appeared at the myocarditis onset and remained the only disease manifestations for several years. During follow-up, the patient was diagnosed with dilated cardiomyopathy, which required heart transplantation.

Cryothermal energy demonstrates shorter ablation time and lower complication rates compared with radiofrequency in surgical hybrid ablation for recurrent ventricular tachycardia

Recurrent ventricular tachycardia (VT) after prior endocardial catheter ablation(s) presents challenges in the setting of prior cardiac surgery where percutaneous epicardial access may not be feasible. The purpose of this study was to compare the outcomes of cryothermal vs radiofrequency ablation in direct surgical epicardial access procedures. We performed a retrospective study of consecutive surgical epicardial VT ablation cases. Surgical cases using cryothermal vs radiofrequency ablation were analyzed and outcomes were compared. Between 2009 and 2022, 43 patients underwent either a cryothermal (n = 17) or a radiofrequency (n = 26) hybrid epicardial ablation procedure with direct surgical access. Both groups were similarly matched for age, sex, etiology of VT, and comorbidities with a high burden of refractory VT despite previous endocardial and/or percutaneous epicardial ablation procedures. The surgical access site was lateral thoracotomy (76.5%) in the cryothermal ablation group compared with lateral thoracotomy (42.3%) and subxiphoid approach (38.5%) in the radiofrequency group, with the remainder in both groups performed via median sternotomy. The ablation time was significantly shorter in those undergoing cryothermal ablation vs radiofrequency ablation (11.54 ± 15.5 minutes vs 48.48 ± 23.6 minutes; P < .001). There were no complications in the cryothermal ablation group compared with 6 patients with complications in the radiofrequency group. Recurrent VT episodes and all-cause mortality were similar in both groups. Hybrid surgical VT ablation with cryothermal or radiofrequency energy demonstrated similar efficacy outcomes. Cryothermal ablation was more efficient and safer than radiofrequency in a surgical setting and should be considered when surgical access is required.

PO-01-026 STEREOTACTIC CARDIAC RADIOTHERAPY FOR RECURRENT VENTRICULAR TACHYCARDIA IN PRESENCE OF WIRELESS LEFT VENTRICULAR ENDOCARDIAL STIMULATION SYSTEM

Cardiac stereotactic body radiotherapy (SBRT) is a novel therapy for refractory ventricular tachycardia (VT). However, there remain knowledge gaps due to limited experience. The wireless stimulation endocardial cardiac resynchronization therapy (WiSE CRT) is a promising method of left ventricular (LV) resynchronization using a receiver electrode implanted in LV and a transmitter implanted in the intercostal space that is connected to a subcutaneous battery. The safety of cardiac SBRT in the presence of WiSE CRT has not been reported. We present a case of successful cardiac SBRT for recurrent VT from the LV apex delivered safely in a patient with WiSE CRT. N/A An 83-year-old man had a history of ischemic cardiomyopathy with LV apical infarct, LV ejection fraction 20%, NYHA Class III, underlying left bundle branch block status post CRT-D placement, severe coronary artery disease, paroxysmal atrial fibrillation, chronic kidney disease stage III, hyperlipidemia and orthostatic hypotension. He had initially presented with appropriate defibrillator discharges due to paroxysmal VT. He underwent catheter ablation of VT originating from the LV apex. The procedure was complicated by pericardial effusion requiring emergent pericardiocentesis. He was discharged on amiodarone but this had to be discontinued due to adverse effects. He had recurrence of VT and defibrillator shock and mexiletine was started. He started experiencing worsening heart failure symptoms. CRT-D interrogation revealed recurrent episodes of VT terminated by antitachycardia pacing and LV lead malfunction with high impedance and elevated capture threshold with loss of LV pacing. He underwent WiSE CRT system implant and the transvenous LV lead was turned off. Subsequently he had multiple admissions for VT storm requiring device therapies despite antiarrhythmic medication changes including sotalol and mexiletine. Therefore, he underwent cardiac SBRT targeting the LV apical substrate with 25 Gy dose delivered in a single fraction. SBRT treatment plan was created by contouring the components of the Wise CRT system and limiting dose to them <10 Gy (Figure). He has been weaned off antiarrhythmic drugs and has had no recurrent VT for 2.5 months since SBRT. Wise CRT function and battery status remained stable with no detrimental effects based on device interrogation till 2.5 months post SBRT. With careful treatment planning, cardiac SBRT can be delivered safely in the presence of WiSE CRT.

A Soccer Shot with Lengthy Consequences—Case Report &amp; Current Literature Review of Commotio Cordis

(1) Background: Commotio cordis, caused by objects being directly delivered to the chest, may cause cardiac arrest in young athletes, even without identifiable structural damage to the sternum, ribs or heart itself. Its prevention and management often remain suboptimal, resulting in dismal outcomes. (2) Case summary: A 32-year semi-professional goalkeeper suffered from a non-penetrating blunt thoracic trauma after being struck by a high-velocity shot during a regional league soccer game. He immediately lost consciousness, collapsed, and was successfully resuscitated through early defibrillation of ventricular fibrillation. After an uneventful follow-up for approximately 6 years, recurrent episodes of ventricular tachycardia occurred, which could ultimately only be prevented by epicardial ablation. (3) Conclusion: Very late recurrences of ventricular tachyarrhythmias may occur after ventricular fibrillation due to blunt chest trauma, even in the primary absence of evident structural myocardial damage.

Abstract 14888: Arrhythmogenic Right Ventricular Cardiomyopathy-Brugada Syndrome Overlap: A Rare Clinical Entity

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) and Brugada syndrome (BS) are inherited disorders that predispose individuals to arrhythmic sudden cardiac death. ARVC is a heart muscle disorder of intercellular junctions resulting from mutations of desmosomal (DS) genes, often leading to heart failure, and monomorphic ventricular tachycardia (VT). BS is a channelopathy due to sodium channel mutations, usually presenting as polymorphic VT without cardiomyopathy. Case presentation: A 35-year-old male with history of migraines presented with syncope resulting in a fall. No family history of arrhythmias or sudden cardiac death. Initial EKG showed wide complex monomorphic VT. Repeat EKG (figure 1), revealed coved ST-segment elevations in V1, V2 consistent with Brugada type 1 pattern. Emergent coronary angiography was unremarkable, and echocardiogram showed left ventricular ejection fraction of 55-60%, right ventricle (RV) outflow tract proximal diameter measured 3.5cm and normal RV function. An implantable cardioverter-defibrillator (ICD) was implanted for secondary prevention. Device interrogation on follow-up showed 11 shocks for recurrent episodes of monomorphic VT and patient was started on quinidine maintenance therapy. He remained symptom-free on subsequent visits. Genetic testing was positive for DSC2, DSP, and TMEM43 mutations associated with ARVC, but negative for genes associated with BS. Cardiac MRI results are pending. Discussion: Our patient has overlapping features of ARVC (genotype and monomorphic VT) and BS (EKG with coved ST elevations in V1, V2). Emerging evidence supports the theory that defects in DS proteins may affect the integrity of voltage-gated sodium channels in cardiac intercalated discs, leading to BS like phenotype. Conclusion: ARVC and BS could be related to the same disease spectrum, but further studies are required to understand pathophysiology, to guide treatment decisions.

Abstract 13576: Stereotactic Cardiac Radiotherapy Reduces Structural Heart Disease Associated Refractory Ventricular Tachycardia - A Metaanalysis

Introduction: Cardiac stereotactic body radiotherapy (SBRT) is a paradigm changing treatment for refractory ventricular tachycardia (VT) in patients with structural heart disease. We sought to review the effectiveness of SBRT reported in published studies. Hypothesis: There is a reduction in VT events after cardiac SBRT. Methods: We performed a comprehensive literature search in PubMed, Embase and Google Scholar including all studies on cardiac SBRT for VT till May 2022. Efficacy was evaluated as random-effects pooled rate ratios (RR) of VT episodes, antitachycardia pacing (ATP) therapies and implantable cardioverter-defibrillator (ICD) shocks post-SBRT (after 6-week blanking) vs. during 3-12 months pre-SBRT, with patients serving as their own controls. Results: We included 12 single-arm studies on cardiac SBRT (90 patients) published 2017-2022 with median follow-up ranging 6-28 months. The pooled RR of VT episodes, ATP therapies and ICD shocks post- vs. pre-SBRT were 0.11 (95% CI 0.06-0.21, p&lt;0.001), 0.09 (95% CI 0.04-0.20, p&lt;0.001), and 0.10 (95% CI 0.05-0.19, p&lt;0.001) as shown in Figure 1. There was significant heterogeneity in results (p&lt;0.00001 for all 3 endpoints). The combined 1- and 2-year overall patient survival was 69% and 56% respectively (Figure 2). Conclusions: Cardiac SBRT reduces recurrent VT episodes and ICD shocks in patients with VT refractory to medical therapy and catheter ablation. There is heterogeneity in results from different studies, likely related to differences in patient selection and treatment techniques. The overall patient survival in this high-risk population compares favorably to data from catheter ablation trials.

Stereotactic Arrhythmia Radioablation for Ventricular Tachycardia (StAR-VT): A Single Institution, Dose De-Escalation, Phase II Trial

<h3>Purpose/Objective(s)</h3> Ventricular tachycardia (VT) is characterized by electrical re-entry within patches of heterogeneous myocardial fibrosis leading to sustained consecutive ventricular beats at a rate > 100 per minute. Implantable cardioverter-defibrillators (ICD) are the main intervention for reducing mortality, however, they are exclusively a symptom-control therapy. Catheter ablation is the standard of care adjunctive therapy for patients who are refractory to medical therapy. Recently, a treatment approach with a stereotactic body radiation therapy (SBRT) to arrhythmogenic scar regions has been described. Initial results, using a single 25 Gy fraction, suggest this technique may improve morbidity for patient's refractory to standard of care therapy. The optimal dose for this therapy remains unclear and major adverse events with 25 Gy have been reported. This clinical trial hypothesizes that refractory VT treated with SBRT in a single fraction of 20 Gy is non-inferior to 25 Gy. <h3>Materials/Methods</h3> Inclusion criteria are age > 18 years, cardiomyopathy, recurrent episodes of monomorphic VT failing standard treatment with at least 1 antiarrhythmic drug and previous electrophysiologic ablation. Exclusion criteria are participants with previous thoracic radiation, connective tissue disease, interstitial pulmonary fibrosis, and pregnancy. Participants with contraindications to electrophysiology studies may be eligible for the study, provided the arrhythmic substrate can be defined through other non-invasive methods. We anticipate an incidence rate of approximately 5 VT events per person-year in participants treated with 25 Gy as a historical comparator based on a previous phase I/II trial. Based on a Poisson distribution, and using a non-inferiority margin of 8.5 events per-year (incident rate ratio of 1.70), recruiting 9 participants will provide 80% power when using a one-sided type I error, set at 0.05. Non-inferiority of 20 Gy relative to 25 Gy will be determined if the upper bound of the one-sided 95% confidence interval for the incidence rate ratio is below the pre-specified non-inferiority margin (incidence rate ratio=1.70). The primary efficacy endpoint is the reduction in arrhythmia burden measured by the total number of VT events and ICD treatments for VT comparing the 6 and 12-month periods after a single fraction of 20 Gy SBRT with a single fraction of 25 Gy in the published literature. Our primary safety endpoint is defined as the rate of severe treatment-related adverse events at ≤ 90 days as defined by the CTCAE v5.0. Secondary endpoints include overall survival, late adverse events, antiarrhythmic drug use, and quality of life. <h3>Results</h3> The Research Ethics Board at the institution has approved this research study and will provide ongoing ethical oversight. <h3>Conclusion</h3> This study is currently recruiting participants. This trial is registered at ClinicalTrials.gov, NCT05258422.

671 First-in-man mapping and ablation of ventricular tachycardia using a novel ablation catheter with microelectrodes and thermocouples

Abstract Aims Catheter ablation (CA) is an important therapeutic option for patients with recurrent ventricular tachycardia (VT). Recently, a novel contact-force sensing catheter (QDOT, Biosense Webster) allowing radiofrequency ablation in a temperature-controlled fashion, equipped with microelectrodes and thermocouples has been developed and tested in very-high power short duration CA of atrial fibrillation. As of today, this catheter has never been used for VT ablation. To describe the safety and short-term clinical performance of the novel QDOT catheter for the ablation of recurrent VT/electrical storm. Methods and results Case 1: a 43-year-old male patient with prior anterior myocardial infarction (MI), left ventricular (LV) dysfunction with an apical aneurysm, and recurrent VT episodes was admitted to our hospital for CA of VT. The patient underwent high-density electroanatomical mapping of the left ventricle using a multipolar catheter (PentaRay, Biosense Webster), which showed an extensive apical dense scar region, corresponding to the ventricular aneurysm. When the QDOT catheter was advanced in that region, late/fragmented potentials were detected by microelectrodes as well as by conventional electrodes. During the procedure, a sustained VT with right bundle branch block (RBBB)-inferior axis morphology and transition in V2 could be induced. We recorder diastolic fragmented potentials inside the aneurysm, where the novel catheter previously showed late/fragmented potentials; radiofrequency energy delivery with conventional settings (40 W) in that area led to rapid arrhythmia termination (Figure A). At the end of the procedure, VTs were no more inducible. Case 2: a 79-year-old male patient with prior inferior MI, mild LV dysfunction with a 5 cm × 5 cm × 3 cm aneurysm of the basal-mid inferior wall, and two previous CAs for recurrent VT presented to our hospital for electrical storm due to multiple episodes of slow VT (cycle, 470 ms, RBBB morphology, inferior axis, transition in V6), which were refractory to antiarrhythmic drug treatment. We decided to perform redo CA using the QDOT catheter, which revealed long and fragmented low-amplitude diastolic potentials inside the LV aneurysm (Figure B). VT was rapidly terminated by means of radiofrequency energy delivery with usual settings (40 W) in this region, and was no more inducible afterwards. Conclusions The novel ablation catheter showed favourable manoeuverability in the ventricle, while also allowing a precise characterization of the tachycardia circuitry and of the arrhythmogenic myocardial substrate, which was enhanced by the availability of microelectrodes. We believe that this preliminary experience may pave the way for further assessments of this new technology in the so far unexplored ventricular milieu.

Mechanism of premature ventricular complexes in a patient with ischemic cardiomyopathy.

A 70-year-old male patient with a history of a large anterior wall myocardial infarction presented to our institute with recurrent episodes of ventricular tachycardia (VT) terminated by anti-tachycardia pacing from his implantable cardioverter-defibrillator (ICD). This article is protected by copyright. All rights reserved.

Effective treatment of electrical storm by a wearable cardioverter defibrillator in a patient with severely impaired left ventricular function after myocardial infarction: a case report

BackgroundThe implantation of cardioverter defibrillators (ICDs) is an established therapy in the prevention of sudden cardiac death in patients with systolic dysfunction after myocardial infarction. To avoid immediate implantation of an ICD, wearable cardioverter defibrillator vests (WCD) can be used to protect patients against malignant rhythm disorders, while at the same time drug-based heart failure therapy has to be initiated. This drug therapy can improve left ventricular ejection fraction and primary prophylactic cardioverter defibrillator implantation may not be necessary. However, the recent Vest Prevention of Early Sudden Death Trial (VEST) questioned the regular use of the WCD in this setting.Case presentationA 47-year-old Caucasian man with severely impaired left ventricular function early after myocardial infarction was prescribed a WCD as primary prophylaxis to prevent sudden cardiac death. Seven days after the patient was supplied with a WCD, the patient suffered from an electrical storm with recurrent ventricular tachycardia (VT), which was successfully terminated 17 times by the WCD. On coronary angiography, the formerly infarct-related right coronary artery had TIMI (Thrombolysis in Myocardial Ischemia Trial) III flow, and a remaining stenosis in the left anterior descending artery (LAD) was stented, which did not stop recurrent VT. In the electrophysiology (EP) study, a focus was mapped in the left inferior ventricle, which was ablated. This stopped the VT. A second radio-frequency (RF) ablation in the same area was necessary after 14 days. Finally, a permanent cardioverter defibrillator was implanted.ConclusionWe report the case of a patient who survived recurrent episodes of VT early after myocardial infarction by effective defibrillation with a WCD. The WCD is a useful device to bridge time until a final decision for implantation of a defibrillator.

Abstract 12974: Successful VT Ablation Utilising Intracoronary Gelatin Sponge Injection

Introduction: We report two cases of recurrent ventricular tachycardia (VT) successfully treated by intra-coronary Gelatin sponge embolization where initial endocardial ablation was unsuccessful and epicardial approaches were unfavourable. Case Histories: (1) A 75-year-old male with Inferior STEMI who underwent PCI to oRPDA developed VT storm that required DCCV 11 times. The VT was hemodynamically unstable, hence only substrate modification was performed. He still had recurrent episodes of VT and a second ablation attempt localised VT circuit breakout to the infero-apical septum, but ablation was unsuccessful due to a deep intramural circuit. Epicardial ablation was not attempted due to a 1cm pericardial effusion after the first procedure. Unipolar signals from selective wiring of the distal rPDA with a percutaneous coronary intervention guidewire and microcatheter showed early local electrograms. 5ml of Gelatin sponge injection was injected after a 5x2mm coil failed to occlude the distal rPDA. Post occlusion, VT was not inducible with double ventricular extra-stimuli. He has been VT free for 5 months (2) A 41-year-old female with dilated cardiomyopathy, previous left ventricular assist device and revision was admitted for VT storm. The VT map identified earliest activation with far-field pre-systolic potentials at the baso-lateral LV segment. Pre-systolic far field ventricular EGMs were also seen in the adjacent coronary sinus, consistent with a likely epicardial exit site of the VT. Endocardial ablation failed, and epicardial access was not feasible due to adhesions. Coronary angiography revealed a small calibre non dominant left circumflex artery supplying the VT exit site. Cold saline injection down the mLCX terminated the VT and the vessel was occluded with 5 ml of Gelatin sponge. VT was subsequently not inducible. Discussion &amp; Conclusion: Critical portions of VT circuits may course epicardially or intramurally 3 , limiting successful endocardial catheter ablation. Epicardial access was risky. Coronary vessel embolization using coils 4 and ethanol 5 have been performed. Use of absorbable Gelatin sponge has been described in managing coronary perforation 6 , but to the best of our knowledge these are the first cases of its use in VT ablation.

An unusual precipitant of acute heart failure-ANCA-associated vasculitis in a patient with ischaemic cardiomyopathy: a case report.

BackgroundAntineutrophil cytoplasmic antibody (ANCA)-associated pulmonary renal vasculitis is an uncommon disease entity. Its presentation as acute heart failure for the first time in a patient with established coronary artery disease (CAD) is even rarer. We present here a case of such an association and an approach to managing this clinical situation.Case summaryA 60-year-old male patient presented to the emergency room with recent-onset dyspnoea New York Heart Association Class IV. He was having hypertension, uncontrolled diabetes mellitus, chronic kidney disease (CKD), and CAD. He also underwent a percutaneous coronary intervention to left anterior descending in the past for acute coronary syndrome and had moderate left ventricular dysfunction. He was being managed as a case of acute decompensated heart failure (ADHF) and was mechanically ventilated. Suddenly his ventilator requirement increased and endotracheal aspirate contained blood. The chest radiograph showed bilateral hilar infiltrates. Simultaneously he also had recurrent episodes of ventricular tachycardia (VT) requiring direct current (DC) cardioversion. Blood investigations showed deranged renal function and severe hyperkalaemia, but no evidence of coagulopathy. High-resolution computed tomography chest showed features of diffuse alveolar haemorrhage. Further investigations revealed high titres of c-ANCA and raised inflammatory biomarkers. A diagnosis of ANCA-associated vasculitis presenting as acute on CKD with dyselectrolytaemia (hyperkalaemia) leading to VT was made. Apart from standard management for associated illness, he was treated with plasma exchange, steroids, and cyclophosphamide to which he responded and was later on discharged.DiscussionAntineutrophil cytoplasmic antibody-related pulmonary renal vasculitis can lead to rapidly progressing renal failure and may present as ADHF in a patient with existent CAD. The associated VT storm in our patient can be attributed to hyperkalaemia secondary to acute renal failure. A multidisciplinary approach is required for the successful management of such a complex clinical scenario.

Deep sedation as temporary bridge to definitive treatment of ventricular arrhythmia storm.

Electrical storm and incessant ventricular tachycardia (VT) are characterized by the clustering of episodes of VT or ventricular fibrillation (VF) and are associated with a poor prognosis. Autonomic nervous system activity influences VT threshold, and deep sedation may be useful for the treatment of VT emergencies. We reviewed data from conscious patients admitted to our intensive care unit (ICU) due to monomorphic VT, polymorphic VT or VF at our tertiary center between 2010 and 2018. A total of 46 conscious patients with recurrent ventricular arrhythmia, refractory to initial treatment, were referred to the ICU. The majority (n = 31) were stabilized on usual care. The remaining treatment-refractory 15 patients (57 years (range 9-74), 80% males, seven with implantable cardioverter-defibrillators) with VT/VF storm (n = 11) or incessant VT (n = 4) due to ischemic heart disease (n = 10), cardiomyopathy (n = 2), primary arrhythmia (n = 2) and one patient post valve surgery, were deeply sedated and intubated. A complete resolution of VT/VF within minutes to hours was achieved in 12 patients (80%), partial resolution in two (13%) and one (7%) patient died due to ventricular free-wall rupture. One patient with recurrent VT episodes needing repeated deep sedation developed necrotic caecum. No other major complications were seen. Thirteen (87%) patients were alive after a mean follow-up of 3.7 years. Deep sedation was effective and safe for the temporary management of malignant VT/VF refractory to usual treatment. In emergencies, deep sedation may be widely accessible at both secondary and tertiary centers and a clinically useful bridge to definitive treatment of VT.

P2877The incidence, predictors, and long-term outcomes of new-onset ventricular tachycardia after cardiac surgery

Abstract Background Incidence and outcomes of new-onset ventricular tachycardia (VT) after cardiac surgery are not fully evaluated. Purpose We retrospectively analyzed the occurrence of new-onset VTs after cardiac surgery, and their implications on short and long-term mortality. Methods Data of 11,004 adult patients who underwent cardiac surgery at our center from 2006 to 2016 were analyzed. VT was diagnosed when 3 or more consecutive wide QRS complexes (&gt;100 bpm) were documented on ECG. The major study outcomes were in-hospital and 5-years overall mortality rates. Results During index hospitalization for cardiac surgery, clinical VTs were documented in 184 patients (1.7%), which included 74 sustained VTs (SusVT, ≥30 seconds) and 110 non-sustained VTs (NSVT). Those patients with SusVT and NSVT showed higher in-hospital mortality compared to those without VTs (31.1% vs. 24.5% vs. 2.0% for SusVT, NSVT, and no VT, respectively, P&lt;0.001). During follow-up after discharge from index hospitalization, patients with SusVT showed higher 5-years mortality than those without VTs, while patients with NSVT did not showed significant differences (22.0% vs. 11.7% vs. 9.2%, P&lt;0.001). In the subgroup of patients with sustained VT who were discharged from index hospitalization (n=51), those with recurrent VTs (&gt;24 hours apart from initial episode) were at higher 5-years mortality rate compared to those without (40.7% vs. 15.8%, P=0.018). Conclusion Patients with SusVT and NSVT were at higher risk of in-hospital mortality, and patients with SusVT were associated with higher risk of long-term mortality. The mortality risk was even higher in those with recurrent episodes of VTs. Acknowledgement/Funding None

Right ventricular free-wall scar: an exceptional source of post-infarction ventricular tachycardia. A case report.

Background In patients with coronary artery disease, ventricular tachycardia (VT) is usually related to left ventricular (LV) post-infarction scars.Case summaryA case of a 78-year-old man with post-infarction VT originating from the right ventricular (RV) free wall is described. Following recurrent episodes of VT with left bundle branch block morphology and left superior axis deviation, a patient with prior myocardial infarction was submitted to catheter ablation. Two areas of abnormal bipolar electrograms were observed at 3D electroanatomical mapping: one located at the basal aspect of the posterior and postero-septal LV, and the other one extending from the antero-lateral to the posterior mid-basal RV free wall. Ventricular late potentials (LPs) were recorded within both scars, but only pacing from those located in the RV resulted in long stimulus-to-QRS latency and optimal pace-mapping. Accordingly, this substrate was deemed the culprit of the clinical VT. Radiofrequency catheter ablation aimed at eliminating all LPs recorded from both scars was effective in preventing VT recurrences at follow-up.DiscussionA post-infarction RV free-wall scar may exceptionally be responsible of VT occurrence. Right ventricular mapping should be considered in selected cases based on 12-lead electrocardiogram VT morphology and prior RV infarct.

Resistant Ventricular Tachycardia due to Idiopathic Left Ventricular Aneurysm: Successful Treatment with Surgery

Left ventricular aneurysms (LVAs) are characterized by a wide connection to the left ventricle and paradoxical systolic motions. Although patients with LVAs are usually asymptomatic, some may present with arrhythmias, heart failure, and even cardiac arrest. In this case report, we describe a 62-year-old male patient who presented to our emergency service with complaints of palpitation and shortness of breath of 2 hours' duration. His blood pressure was 84/56 mm Hg, and he was in a confused state. An electrocardiogram revealed ventricular tachycardia (VT) with right bundle branch block and a ventricular rate of 188 bpm. The patient's hemodynamic instability necessitated a direct current cardioversion, which restored the sinus rhythm. During the in-hospital course, he had numerous recurrent VT episodes despite treatment with intravenous amiodarone and magnesium sulfate as well as radiofrequency ablation. Upon consensus with a cardiovascular surgeon's team, urgent surgery was performed due to the resistant VT episodes. The patient's clinical course was uneventful, and he was discharged on the 11th postoperative day. We have been following up the patient for almost 1 year, during which he has not experienced palpitations or associated symptoms. Our case indicates that surgery may be a preferable treatment option for patients with heart failure and resistant VT related to LVAs.

Sudden Cardiac Death in Acute Coronary Syndromes.

Sudden cardiac death in acute coronary syndromes mostly results from complex ventricular arrhythmias. Although the incidence has fallen with contemporary management, they still pose a threat for many patients. Treatment consists of immediate termination by electrical cardioversion and prompt coronary revascularization for relief of ischemia. Beta-blockers administered prophylactically have a protective effect. For recurrent episodes, pharmacologic treatment consists of beta-blockers and amiodarone, or, in nonresponsive patients, lidocaine. Other antiarrhythmic drugs play only a marginal role. Catheter ablation performed in qualified centers can be effective in recurrent episodes of ventricular tachycardia or ventricular fibrillation triggered by premature ventricular contractions.

Limitations and Challenges in Mapping Ventricular Tachycardia: New Technologies and Future Directions.

Recurrent episodes of ventricular tachycardia in patients with structural heart disease are associated with increased mortality and morbidity, despite the life-saving benefits of implantable cardiac defibrillators. Reducing implantable cardiac defibrillator therapies is important, as recurrent shocks can cause increased myocardial damage and stunning, despite the conversion of ventricular tachycardia/ventricular fibrillation. Catheter ablation has emerged as a potential therapeutic option either for primary or secondary prevention of these arrhythmias, particularly in post-myocardial infarction cases where the substrate is well defined. However, the outcomes of catheter ablation of ventricular tachycardia in structural heart disease remain unsatisfactory in comparison with other electrophysiological procedures. The disappointing efficacy of ventricular tachycardia ablation in structural heart disease is multifactorial. In this review, we discuss the issues surrounding this and examine the limitations of current mapping approaches, as well as newer technologies that might help address them.

Recurrent episodes of ventricular tachycardia in the patient with LV aneurysms, improved after LV aneurysmectomy

Recurrent episodes of ventricular tachycardia in the patient with LV aneurysms, improved after LV aneurysmectomy