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