Case presentation

ByJohn Kamel Zarif

lecturer of cardiologyAin-Shams university

61 years old male patient, diabetic, hypertensive, ex-smoker.

10 years ago, he suffered from an anteroseptal MI with no reperfusion therapy had been taken.

Because of syncopal attack in feb2008, thalium cardiac scan was done which revealed a moderate sized scar in anteroseptal region with no residual viability and minimal peri-infarct ischemia

ECHOcardiography

Mildly dilated LV (60X43)Fair LV systolic function, EF = 47%Akinesia of all apical segments, mid

septum, mid anterior wall with starting apical aneurysm

coronary angiography was done which revealed non-significant LAD lesion

May2008, he suffered from one attack of documented VT which was haemodynamically stable and he had received DC cardioversion.

He was kept on amiodarone therapy. Feb2010, another 2 attacks of stable VT

had occurred inspite of antiarrhythmic drugs, DC cardioversion were done twice.

Mar2010, ICD implanted He received 19 ICD Shocks in one month

for frequent recurrent VT inspite of good treatment and no correctable causes.

So He was refereed for trial of substrate ablation or modification

Resting ECG

Clinical tachycardia

Induction of clinical tachycardia

Intracardiac tracing of VT

Voltage map

Activation map showing an Early potential

Activation map showing a late potential

Diastolic potentials

Entrainment mapping with 12/12 pacemap

DP-QRS interval

DP-QRS = S-QRS

Return cycle length after entrainment

During ablation

VT2 VT1

Diastolic potentials And DP-QRS interval

Entrainment mapping with 12/12 pacemap

DP-QRS = S-QRS

Return cycle length after entrainment

During ablation

FAST VT

Total procedure time: 3 hoursFluoroscopy time: 60 min Complication: none

Take home message Ablation of scar related VT is feasible in

the era of 3D CARTO mapping system with more than 70% success rate.

Catheter ablation is indicated as adjunctive therapy in patients with structural heart disease and an ICD who are receiving multiple shocks as a result of sustained VT that is not manageable by reprogramming or changing drug therapy or who don’t wish long tem drug therapy( class I, level of evidence: C)

Combination of entrainment map with activation map

- Increases the effectiveness of ablation.- Decreases the complications of unwanted

ablation lesions