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Epicardial Ablation of Ventricular Tachycardia: Unveiling the Challenges and Charting for Solutions
Session:
Casos Clínicos: Arritmias e Dispositivos Cardíacos
Speaker:
Joao Santos Fonseca
Congress:
CPC 2024
Topic:
C. Arrhythmias and Device Therapy
Theme:
04. Arrhythmias, General
Subtheme:
04.4 Arrhythmias, General – Treatment
Session Type:
Sessão de Casos Clínicos
FP Number:
---
Authors:
Joao Santos Fonseca; Nuno Cortez Dias; Angelo Nobre; Ilda Viana; Ceu Barreiros; Joana Quaresma; Joao Agostinho; Fausto J. Pinto; Joao de Sousa
Abstract
<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">We report the case of a 59-year-old man with ischemic heart disease (significant lesion in LAD), rheumatic valvular cardiopathy with mechanical aortic and mitral prosthesis since 1987, iatrogenic hyperthyroidism, and moderate renal insufficiency. Cardiac Magnetic Resonance (CMR) showed an ischemic pattern of the inferior, lateral and apical segments, without viability, and severe reduction of left ventricular ejection fraction (20%). A CRT-D was implanted in March 2022.</span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">The patient had recurrent VT and several episodes of electrical storm in the previous 2 years, despite optimized treatment with amiodarone and mexiletine. His VT rate was 160 bpm, with right bundle branch block-like morphology, left inferior axis and negative QRS in V3-V4.</span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">ADAS-3D<sup>R</sup> mapping software was used to integrate angio-computerized tomography and CMR information. Imaging showed right ventricle distortion and adhesions to the sternum; making conventional sub-xiphoid epicardial access not viable. The left ventricle was severely dilated, with scar areas in the apex, basal and medium segments of the inferior-lateral and inferior walls, as well as, basal segment of the anterior septum. Subepicardial channels were predicted in the apex and medium segments of the anterior-lateral, inferior-lateral and inferior walls; intramural in the basal segments of the inferior-lateral wall; and endocardial in the basal segment of the anterior septum. </span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">Epicardial VT ablation was conducted under general anesthesia, inotropic support with low dose norepinephrine and transesophageal echocardiography. Through a left lateral minithoracotomy, pericardial adhesions were debrided to allow access of the mapping tools. A high density electroanatomic map of the accessible segments was obtained with Carto System<sup>R</sup> and an Octaray<sup>R</sup> multipolar catheter during apical pacing from the right ventricle. Multiple areas of fractioned and late potentials (LAVA) were detected in the topographies predicted in the CMR with a high accuracy match. VT was induced and mid-diastolic potentials were recorded, from the entry-site (infero-apical segment) to the exit-site (antero-apical segment). Ablation was performed with a SmartTouch<sup>R</sup> ablation catheter positioned in the apical channel, with subsequent tachycardia termination. Radiofrequency was applied to other regions with abnormal LAVA in the medium segments of the antero-lateral and infero-lateral walls. After ablation, mapping showed abolition of LAVA in the ablated regions.</span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">Patient recovery was uneventful, except for a hemothorax that required surgical drainage. After a 6-months follow up, patient remains free from sustained ventricular arrhythmia.</span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">This report illustrates the key role of catheter epicardial mapping and ablation in challenging VTs, with a critical component of the circuit located epicardially, and the need for a multidisciplinary medical and surgical team approach.</span></span></p>
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