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Images and Case Reports in Arrhythmia
and Electrophysiology
Ablation of Ventricular Tachycardia in Chronic Chagasic
Cardiomyopathy With Giant Basal Aneurysm
Carto Sound, CT, and MRI Merge
Bruno P. Valdigem, MD; Fabio B.F.C.G. Pereira, MD; Nilton J. Carneiro da Silva, MD;
Cristiano O. Dietrich, MD; Ricardo Sobral, MD; Fernando Lopes Nogueira, MD;
Roberto C. Berber, MD; Fabricio Mallman, MD; Ibraim M. Pinto, MD; Gilberto Szarf, MD;
Claudio Cirenza, MD, PhD; Angelo A.V. de Paola, MD, PhD
C
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potentials (Figure 4, left) and concealed entrainment indicated an endocardial circuit isthmus located between the
aneurysm proximal border and the mitral valve. When the
endocardial circuit was localized, radiofrequency energy was
delivered interrupting the VT. Late potentials could be seen
on that site, and they were also targeted (Figure 4, right). An
implantable cardioverter-defibrillator was implanted and the
patient remained free of the clinical VT.
Intracardiac echocardiogram integration with electroanatomical mapping is a novel tool for image integration and
may improve anatomy visualization for catheter ablation of
cardiac arrhythmias.1–3
hronic chagasic cardiomyopathy (CCC) is a parasitic
disease that presents with life-threatening ventricular
arrhythmias, dilated cardiomyopathy, or sudden death. Basal
and posterior wall motion abnormalities and left apical
aneurysms are common.
We present a report of a patient with CCC, sustained
ventricular tachycardia (VT) refractory to amiodarone 400
mg/day and carvedilol 25 mg/day BID with a giant left basal
aneurysm as visualized by CT scan and intracardiac echocardiogram 3D reconstruction(Carto Sound). The patient underwent preprocedural CT scan data acquisition with 64-slice
MDCT scanner Aquilion (Toshiba, Tochigi, Japan), and the
images were used for 3D reconstruction with Cartomerge
(Biosense Webster, Inc., Diamond Bar, CA). Images acquired
using cardiac MRI confirmed the size and shape of the
aneurysm. No significant scar was observed in other areas of
the LV. Images of the CT Scan and Carto Sound acquired
with Soundstar catheter and electroanatomic mapping were
merged and ablation was performed with a 3.5-mm cooled-tip
catheter (Figures 1 and 2). Programmed right ventricular
stimulation with 2 extra stimuli induced sustained VT. Endocardial and epicardial mapping was performed in sinus
rhythm (voltage mapping) and during VT (activation mapping). During epicardial mapping in sinus rhythm, surface
voltage exceeded 1.5 mV, and during VT no evidence of
epicardial circuit was found. Intracardiac echocardiography
with image integration was helpful for catheter tip location
(Figure 3) and ablation of the aneurysm border. Mid-diastolic
Disclosures
None.
References
1. Ferguson JD, Helms A, Mangrum JM, Mahapatra S, Mason P, Bilchick
K, McDaniel G, Wiggins D, DiMarco JP. Catheter ablation of atrial
fibrillation without fluoroscopy using intracardiac echocardiography and
electroanatomic mapping. Circ Arrhythm Electrophysiol. 2009;2:
611– 619.
2. den Uijl DW, Tops LF, Tolosana JM, Schuijf JD, Trines SA, Zeppenfeld
K, Bax JJ, Schalij MJ. Real-time integration of intracardiac echocardiography and multislice computed tomography to guide radiofrequency
catheter ablation for atrial fibrillation. Heart Rhythm. 2008;5:1403–1410.
3. Tian J, Smith MF, Jeudy J, Dickfeld T. Multimodality fusion imaging
using delayed-enhanced cardiac magnetic resonance imaging, computed
tomography, positron emission tomography, and real-time intracardiac
echocardiography to guide ventricular tachycardia ablation in implantable
cardioverter-defibrillator patients. Heart Rhythm. 2009;6:825– 828.
Received July 14, 2010; accepted November 8, 2010.
From the Federal University of São Paulo, São Paulo, Brazil.
The online-only Data Supplement is available at http://circep.ahajournals.org/cgi/content/full/CIRCEP.110.957571/DC1.
Correspondence to Bruno Pereira Valdigem, 715 Rua Napoleão de Barros, Setor de Hemodinâmica, Vila Clementino, São Paulo, Brazil. E-mail
[email protected]
(Circ Arrhythm Electrophysiol. 2011;4:112-114.)
© 2011 American Heart Association, Inc.
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org
112
DOI: 10.1161/CIRCEP.110.957571
Valdigem et al
Giant Aneurysm in Chagas: Carto Sound, CT and MRI
113
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Figure 1. Comparison of CT scan and ICE-3D reconstructed images. Two different maps were used to get a better definition of the
aorta and cusps and the LV epicardium. Left, The ascending aorta and its relation to the endocardial LV voltage map are visible. Right,
The anatomy of the three cusps. Red indicates areas of amplitude ⬍0.52 mV; purple, amplitude ⬎1.51 mV (same voltage scale as
Figure 2).
Figure 2. Integration of images was performed using the coronary cusps and coronary ostia as visualized by ICE, the endocardial voltage EA map, and the CT scan data. Red indicates
areas of amplitude ⬍0.52 mV; purple, amplitude ⬎1.51 mV.
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Circ Arrhythm Electrophysiol
February 2011
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Figure 3. Images were acquired in real time during ablation. Left, A view with only ICE. Right, An LV endocardial voltage map is combined with CT scan data reconstruction. The catheter tip is near the mitral valve, and the aneurysm borders are clearly visible, as well
as the distance between the proximal and the distal borders of the aneurysm. Red indicates areas of amplitude ⬍0.52 mV; purple,
amplitude ⬎1.51 mV.
Figure 4. Left, Clinical VT induced and nid-diastolic potentials. Middle, ICE-3D endocardial LV activation map in sinus rhythm with successful ablation target highlighted. Right, VT termination during ablation in a site with late fragmented potentials. The dashed red circle
indicates the catheter tip position during the events described in the left and right panels (mid-diastolic potentials, VT termination during
ablation, and late potentials).
Ablation of Ventricular Tachycardia in Chronic Chagasic Cardiomyopathy With Giant
Basal Aneurysm: Carto Sound, CT, and MRI Merge
Bruno P. Valdigem, Fabio B.F.C.G. Pereira, Nilton J. Carneiro da Silva, Cristiano O. Dietrich,
Ricardo Sobral, Fernando Lopes Nogueira, Roberto C. Berber, Fabricio Mallman, Ibraim M.
Pinto, Gilberto Szarf, Claudio Cirenza and Angelo A.V. de Paola
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Circ Arrhythm Electrophysiol. 2011;4:112-114
doi: 10.1161/CIRCEP.110.957571
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