Download Successful Catheter Ablation of Ischemic Ventricular Tachycardia

Successful Catheter Ablation of Ischemic Ventricular Tachycardia From Apical Free
Wall of Left Ventricle
Jayantika K, Raharjo SB, Karolina W, Kristyagita A, Ahnaf F, Patria B
Arrhythmia Division, Department of Cardiology and Vascular Medicine, National
Cardiovascular Centre Harapan Kita (NCCHK) Hospital Jakarta, Faculty of Medicine
University of Indonesia/University of Udayana 2016
Background : Implantable cardioverter-defribilators (ICD) are currently the mainstay of
tratment for ischemic heart disease who are at risk for sudden cardiac death due to VT. ICD is
effective to terminate VT, but do not prevent VT episodes. Catheter ablation now has important
role in control incessant VT and to reduce or prevent reccurrent episodes of sustained VT.
Case Illustration : A case of male, 39 y.o., hypertensive, ex-smoker, dyslipidemic, 2 vessels
CAD, low EF, and history of recurrent VT. ECG showed frequent VPC and non-sustained VT.
Patient diagnose with substrate VT/VPCs caused by ischemic, and undergo catheter ablation.
During LV geometry, patient developed non-sustained VT with 5 different morphologies.
Voltage mapping showed scar area of apical free wall, septal, and basal posterior LV. Pace
mapping at LV free wall showed 11/12 similarity with VPC (clinical VT). Clinical VT was
inducible and activation mapping showed the earliest activation area was at apical LV free
wall, compatible the voltage and pace mapping. Apical LV free wall were isolated and ablated
by means of point by point. After ablation an agressive pacing with S1S2 and S3 could not
induced clinical VPC/VT. At follow up after discharge, holter only shows infrequent simple
benign VPC.
Discussion : Recurrent episodes of VT in CAD defined by scars causing reentry circuit. The
exit site gives rise to QRS complex and is often the initial target during ablation. Defining the
area of scar for substrate mapping necessitates geometry, voltage, and pace mapping. Voltage
mapping of scarred myocardium will show multiple low amplitude of < 1.5 mV. Pace mapping
should then be performed to identify wheter these sites are critical to the reentry circuit. Those
sites in scar, or along the border where pacing produce similarity of QRS morphology with VT
or VPCs. A perfect pace map will replicate VT QRS morphology in ECG (12/12 match). If VT
is inducible and hemodynamically stable, activation mapping during tachycardia can show
circuit exit and earliest activation site. Radiofrequency ablation is commonly used for ablation.
Coclussion : We reported a case of successful ischemic VT ablation from apical free wall left
ventricle.