Unconventional warfare: Successful ablation of ventricular tachycardia by direct ventricular puncture in a patient with double mechanical heart valves

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Presentation transcript:

Unconventional warfare: Successful ablation of ventricular tachycardia by direct ventricular puncture in a patient with double mechanical heart valves S. Divakara Menon, MD, MSc, Richard Whitlock, MD, FRCSC, Nicholas Valettas, MD, FRCPC, Jeff S. Healey, MD, MSc, FRCPC, FHRS HeartRhythm Case Reports Volume 3, Issue 12, Pages 599-603 (December 2017) DOI: 10.1016/j.hrcr.2017.10.007 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 Twelve-lead and intracardiac recordings of clinical ventricular tachycardia (VT). A: A 12-lead rhythm strip of VT showing right bundle branch block with left axis deviation. B: Intracardiac recordings from the endocardial left ventricle. There is a presystolic potential (arrow) preceding the onset of the QRS complex. C: Termination of the VT during ablation at the site shown in panel B. Note the late potential in diastole (dotted arrow) that preceded the QRS during VT, indicating the slow conducting isthmus involved in the tachycardia circuit. Abl D = ablation distal; Abl P = ablation proximal; Abl Uni = ablation unipolar. HeartRhythm Case Reports 2017 3, 599-603DOI: (10.1016/j.hrcr.2017.10.007) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 CARTO electroanatomic activation map during ventricular tachycardia (VT). A: Endocardial map showing earliest activation occurring at the mid-inferior wall of the left ventricle (LV). B: Limited epicardial activation map. Early activation is diffuse, which indicates that the VT exit is not epicardial. C: Electroanatomic maps of the right ventricle (RV), LV, coronary sinus (CS), and epicardium, showing the exit of the tachycardia at the inferior endocardial surface of the LV. HeartRhythm Case Reports 2017 3, 599-603DOI: (10.1016/j.hrcr.2017.10.007) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 A: Coronary angiogram of the left coronary artery system. Collaterals to the right system are seen (arrow) overlying the scarred area. Calcification of the scar is also seen (asterisk). B: Right coronary angiogram. Total occlusion of the distal right system with faint collateralization to the left circumflex artery is seen. C: Exposure of the left ventricle (LV) lateral wall and introduction of a SafeSheath Hemostatic Peel Away Introducer to the LV cavity through the free wall puncture. HeartRhythm Case Reports 2017 3, 599-603DOI: (10.1016/j.hrcr.2017.10.007) Copyright © 2017 Heart Rhythm Society Terms and Conditions