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Eur Heart J Case Rep
Eur Heart J Case Rep
ehjcr
European Heart Journal. Case Reports
2514-2119
Oxford University Press UK

10.1093/ehjcr/ytae484
ytae484
Images in Cardiology
AcademicSubjects/MED00200
Eurheartj/1
Eurheartj/7
Turning the corner in a one-stop-shop: protected ventricular tachycardia ablation and pulmonary vein isolation in late-stage heart failure
Winnik Stephan Department of Cardiology, Zurich Regional Health Center, Wetzikon, ZH 8620, Switzerland
Department of Cardiology, University Heart Center Zurich, ZH 8091, Switzerland

https://orcid.org/0009-0009-1230-9260
Braun Martin Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Med. Fakultät OWL (Universität Bielefeld), Bad Oeynhausen, 32545, Germany

https://orcid.org/0009-0001-4107-5178
El Hamriti Mustapha Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Med. Fakultät OWL (Universität Bielefeld), Bad Oeynhausen, 32545, Germany

https://orcid.org/0000-0003-0490-5862
Sohns Christian Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Med. Fakultät OWL (Universität Bielefeld), Bad Oeynhausen, 32545, Germany

ter Bekke Rachel M A Handling Editor
Hillmann Henrike Aenne Katrin Editor
Ranganathan Deepti Editor
Corresponding author. Tel: +49-5731-973300, Email: csohns@hdz-nrw.de
Conflict of interest: None declared.

9 2024
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© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.
2024
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pmcAn 82-year-old patient with end-stage heart failure secondary to ischaemic cardiomyopathy and ventricular arrhythmias was referred to our centre for management of recurrent electrical storm. The patient experienced multiple ventricular fibrillation episodes that were triggered by non-sustained ventricular arrhythmias related to myocardial scar and rapidly conducted atrial fibrillation (AF). The patient required repetitive cardiopulmonary resuscitation and multiple defibrillations despite intensive medical antiarrhythmic treatment. Progression of his coronary artery disease with history of coronary artery bypass graft surgery was ruled out by coronary angiography; the left ventricular ejection fraction was 20%.

A bailout catheter ablation aiming for left ventricular (LV) substrate modification and circumferential pulmonary vein isolation (PVI) was performed in general anaesthesia. To allow safe mapping and ablation, short-term mechanical circulatory support using an Impella CP (Abiomed) was implemented (Figure 1).

Figure 1 Electroanatomical maps using an OCTARAY® catheter of the left atrium and left ventricle following PVI and substrate modification, respectively, using Carto UNIVU. (A, C) Right anterior oblique (RAO). (B, D) Antero-posterior (AP). (Red) Ablation tags, (asterisk) Impella CP within left ventricle. (E) Fluoroscopy with Impella CP in place in left anterior oblique and RAO view (F). CS, coronary sinus catheter; RVA, catheter in right ventricular apex; ICD, implantable cardioverter defibrillator.

Mapping was carried out using a multipolar catheter and a 3D navigation system. An endocardial bipolar voltage map revealed scar at the basal and inferior LV. Ventricular tachycardia (VT) was induced, and the earliest myocardial activation was observed at the infero-basal LV. Catheter ablation was conducted using a contact-force catheter with a temperature-controlled ablation mode. Ablation resulted in termination of VT. Afterwards, LV scar was targeted in terms of substrate modification, after which VT was no longer inducible. To also tackle AF as VT trigger, LV ablation was followed by successful PVI using very-high-power-short-duration. Thereafter, mechanical circulatory support was removed and the patient extubated. The patient remained free from arrhythmia episodes for 6 months.

Acknowledgements

We are grateful for our enthusiastic physician and nursing team.

Consent: The patient provided written consent to the publication of his case.

Funding: None.

Data availability

Data will be made available from the authors on reasonable request.
