A case of incessant VT from an intramural septal focus: Ethanol or bipolar ablation? Benjamin Berte, MD, Nicolas Derval, MD, Frederic Sacher, MD, PhD,

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Presentation transcript:

A case of incessant VT from an intramural septal focus: Ethanol or bipolar ablation? Benjamin Berte, MD, Nicolas Derval, MD, Frederic Sacher, MD, PhD, Seigo Yamashita, MD, PhD, Michel Haïssaguerre, MD, PhD, Pïerre Jaïs, MD, PhD HeartRhythm Case Reports Volume 1, Issue 3, Pages 89-94 (May 2015) DOI: 10.1016/j.hrcr.2015.01.019 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Clinical ventricular tachycardia. A: Monomorphic clinical ventricular tachycardia (tachycardia cycle length 408 ms) with inferior axis and QS morphology in lead V1, suggesting an exit site at the aortomitral continuity. The patient is in permanent atrial fibrillation. B: In the electrophysiology laboratory, we observed poorly tolerated sustained ventricular tachycardia episodes. HeartRhythm Case Reports 2015 1, 89-94DOI: (10.1016/j.hrcr.2015.01.019) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 A Perfect local pace map (first 5 paced beats) at the septal left ventricular outflow tract site illustrating a 12/12 pace-map match with the initiating premature ventricular contraction, followed by 5 paced beats from the right ventricular apex (device) followed by the initiating premature ventricular contraction and the clinical ventricular tachycardia. B: Anteroposterior view of the local activation map made by the CARTO3, demonstrating earliest activation (focal red spot) at the aortomitral continuity. C: Local electrogram at the ablation site, showing a low-voltage sharp electrogram 34 ms before QRS onset of the clinical ventricular tachycardia and an isoelectric phase followed by a QS morphology on the unipolar. CS = coronary sinus; d = distal; p = proximal; RF = radiofrequency; UNI = unipolar recording. HeartRhythm Case Reports 2015 1, 89-94DOI: (10.1016/j.hrcr.2015.01.019) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 Different regions are mapped in the outflow tract region: 1. Septal LVOT: small presystolic sharp signal at −22 ms from the onset of the QRS. 2. Great cardiac vein: local signal at +32 ms from the onset of the QRS. 3. Aortic cusps: presystolic local signal −4 ms from the onset of the QRS. 4. RVOT: local electrogram at −14 ms compared with the onset of the QRS. 5. Intraseptal: the unipolar signal of the guidewire shows a QS signal slightly before (±24 ms) the onset of the QRS. The exact onset of the unipolar signal was not easy to define in this case. CS = coronary sinus; d = distal; LVOT = left ventricular outflow tract; p = proximal; RF = radiofrequency; RVOT = right ventricular outflow tract. HeartRhythm Case Reports 2015 1, 89-94DOI: (10.1016/j.hrcr.2015.01.019) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 4 Selective ethanol injection into a septal perforator. Left panel with fluoroscopic views: Upper panel: left coronary angiography before injection. Distal branch of septal perforator is the target to cannulate (arrow). Middle panel: left coronary angiography with 1 guidewire inside the first and 1 guidewire inside the second perforator (arrow). Lower panel: angiography after ethanol injection. A distal branch (arrow) of the second perforator is occluded. A: Injection of iced saline. Fast VT with disappearance of VT, after 30 seconds. B: Injection of ethanol. Single premature ventricular contraction, with no VT afterward. C: Final result. Complete eradication of VT and premature ventricular contraction after a couple of minutes. VT = ventricular tachycardia. HeartRhythm Case Reports 2015 1, 89-94DOI: (10.1016/j.hrcr.2015.01.019) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 5 Different ablation techniques for intraseptal or intramural scar. A: Illustration of merged multidetector computed tomography/magnetic resonance imaging segmentation with postablation nontransmural scar regions (in yellow) on both sites of the septum (left anterior oblique view). Blue, ablation catheters; gray, tip; white, needle; read dot, ablation target; orange dot, expected ablation lesion; red, first septal perforator. 1. High output ablation (till 70 W) gives a slightly larger lesion; however, often not transmural and the risk of steam pop or catheter perforation increases. 2. Bipolar ablation. Two ablation catheters at opposing septum sites. (B: Anteroposterior view, 2 ablation catheters in steerable sheaths and an RV apex catheter for pacing purposes). 3. Irrigated needle catheter at LV septum. Needle extended (7–9 mm) inside the septum with staining of contrast. (C: fluoroscopic image with contrast staining at another basolateral site. Needle catheter in steerable sheath, and quadripolar catheter in coronary sinus and RV apex. Dual-chamber implantable cardioverter-defibrillator leads image). 4. Selective coronary ethanol injection (cf fluoroscopic sequence). D: Coronary angiogram shows septal perforators, with the first septal perforator as target (arrow). E: Guidewire cannulation of first (arrow) and second septal perforator. F: Balloon occlusion (arrow) with iced saline injection and later with 1.5-mL ethanol injection because of ventricular tachycardia termination. G: Occlusion of the first septal perforator (arrow). LV = left ventricular; RV = right ventricular. HeartRhythm Case Reports 2015 1, 89-94DOI: (10.1016/j.hrcr.2015.01.019) Copyright © 2015 Heart Rhythm Society Terms and Conditions