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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 Downloaded from http://circep.ahajournals.org/ by guest on May 2, 2017 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 Downloaded from http://circep.ahajournals.org/ by guest on May 2, 2017 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. 114 Circ Arrhythm Electrophysiol February 2011 Downloaded from http://circep.ahajournals.org/ by guest on May 2, 2017 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 Downloaded from http://circep.ahajournals.org/ by guest on May 2, 2017 Circ Arrhythm Electrophysiol. 2011;4:112-114 doi: 10.1161/CIRCEP.110.957571 Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2011 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-3149. Online ISSN: 1941-3084 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circep.ahajournals.org/content/4/1/112 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation: Arrhythmia and Electrophysiology can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation: Arrhythmia and Electrophysiology is online at: http://circep.ahajournals.org//subscriptions/