Epicardial access and ventricular tachycardia ablation in a postmyocarditis patient using a nonfluoroscopic catheter visualization system Akiko Ueda,

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Epicardial access and ventricular tachycardia ablation in a postmyocarditis patient using a nonfluoroscopic catheter visualization system Akiko Ueda,

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Epicardial access and ventricular tachycardia ablation in a postmyocarditis patient using a nonfluoroscopic catheter visualization system Akiko Ueda, MD, Mika Nagaoka, MD, Kyoko Soejima, MD, Yosuke Miwa, MD, Noriko Matsushita, MD HeartRhythm Case Reports Volume 3, Issue 9, Pages 411-414 (September 2017) DOI: 10.1016/j.hrcr.2017.05.003 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 Puncture system and images of MediGuide demonstrating epicardial puncture. A: A Y connector is attached to the epidural needle for the guidewire insertion and contrast agent injection. B, C: Coronary angiography images obtained with right (B) and left (C) anterior oblique are stored as background images for the MediGuide system. An end of the MediGuide-enabled guidewire set at the tip of the epidural needle is depicted in yellow and indicated with a white arrowhead. The needle was safely advanced without the use of live radiographs. D: A small amount of contrast agent was injected when the needle was advanced to the pericardium (live image). E: The wire was successfully advanced to the epicardial space without the use of live radiographs. HeartRhythm Case Reports 2017 3, 411-414DOI: (10.1016/j.hrcr.2017.05.003) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 Epicardial voltage map and pace map. A: The epicardial voltage map (posteroanterior caudal view) during sinus rhythm demonstrates low-voltage area at the basolateral to inferior wall. Pace mapping was performed at sites A, B, C, and D. B: Surface electrograms of the target ventricular tachycardia (VT) and pace map at sites A to D corresponding to those in Figure 2A are shown. Note that the stimulus-QRS interval is longer at sites deep within the low-voltage area and gradually shortened toward the border area. HeartRhythm Case Reports 2017 3, 411-414DOI: (10.1016/j.hrcr.2017.05.003) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 Elimination of delayed potentials and activation mapping pre- and postablation. A: A surface electrogram of leads II and V1, along with the intracardiac electrogram of the ablation catheter during radiofrequency (RF) energy application, are shown. The delayed potential is gradually prolonged (third beat) and finally eliminated (fourth beat) during RF delivery. B: A late potential map, which displays the latest activation of the electrogram during the sinus rhythm, is shown (left panel: preablation, right panel: postablation). The end of the QRS complex is used as a timing reference. Red and purple colors indicate early and late timing, respectively. Potentials with the latest timing were distributed in the low-voltage areas (see Figure 2A). Note that highly delayed potentials seen in the left map are no longer recorded after ablation at the border of the scar. RF energy was not applied to the latest area because of the proximity to the coronary artery. The ablation sites are indicated by red circles. HeartRhythm Case Reports 2017 3, 411-414DOI: (10.1016/j.hrcr.2017.05.003) Copyright © 2017 Heart Rhythm Society Terms and Conditions