Mapping of a postinfarction left ventricular aneurysm–dependent macroreentrant ventricular tachycardia Elad Anter, MD, Jianqing Li, MD, Cory M. Tschabrunn,

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Mapping of a postinfarction left ventricular aneurysm–dependent macroreentrant ventricular tachycardia Elad Anter, MD, Jianqing Li, MD, Cory M. Tschabrunn, CEPS, Reza Nezafat, PhD, Mark E. Josephson, MD HeartRhythm Case Reports Volume 1, Issue 6, Pages 472-476 (November 2015) DOI: 10.1016/j.hrcr.2015.07.011 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Twelve-lead electrocardiograms. A: A 12-lead electrocardiogram (ECG) during sinus rhythm. B: The 12-lead ECG of the ventricular tachycardia (VT). The VT cycle length was 360 milliseconds with a left bundle branch block pattern and a left superior axis, suggestive of a left ventricular basal septal exit site. Lead II shows atrioventricular dissociation. HeartRhythm Case Reports 2015 1, 472-476DOI: (10.1016/j.hrcr.2015.07.011) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 Activation map of the ventricular tachycardia (VT) circulating around the base of the aneurysm. A: Color-coded activation map of the reentrant VT circulating around the edge of the aneurysm. Red represents early activation and purple represents late activation. The range of colors between red and purple represent intermittent activation time as depicted in the circular color bar. The impulse propagated in a clockwise orientation (dashed arrows) exiting the zone of slowest activation (yellow star) at the septal aspect of the aneurysm, resulting in a left bundle branch block pattern with a left superior axis. B: Example of local activation time annotation by the automated software. The panel shows 4 electrocardiogram leads, 2 unipolar electrograms (Uni-1 and Uni-2), and a resultant bipolar signal (Bipolar). The bipolar signal is multicomponent and fractionated. Determination of activation time (yellow dotted line) was based on the maximal negative slope (−dV/dt) of the unipolar electrogram (Uni-2). HeartRhythm Case Reports 2015 1, 472-476DOI: (10.1016/j.hrcr.2015.07.011) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 Entrainment and termination of the ventricular tachycardia (VT) at the protected isthmus. A: Entrainment from the area of slowest conduction velocity at the superior aspect of the aneurysm below the septal aspect of the mitral annulus (Figure 2 yellow star). Pacing at 20 milliseconds faster than the tachycardia entrained the VT with concealed QRS fusion and a postpacing interval that equaled the tachycardia cycle length. In addition the stimulus-to-QRS was similar to the electrogram-to-QRS interval and was 50% of the tachycardia cycle length, consistent with a protected isthmus site. B: Termination of the VT with a single radiofrequency application. The tachycardia progressively slowed from 360 milliseconds to 420 milliseconds and terminated with the nonpropagated electrogram (solid black arrow). The ablation site was at the base of the aneurysm below the septal aspect of the mitral annulus as it showed atrial (A) and ventricular electrograms. HeartRhythm Case Reports 2015 1, 472-476DOI: (10.1016/j.hrcr.2015.07.011) Copyright © 2015 Heart Rhythm Society Terms and Conditions