Case report Herzschr Elektrophys 2014 DOI 10.1007/s00399-014-0311-0 © Springer-Verlag Berlin Heidelberg 2014
Anja Schade · Karin Nentwich · Thomas Deneke Klinik für Kardiologie II (Interventionelle Elektrophysiologie), Herz-und Gefäßklinik Bad Neustadt a.d. Saale, Germany
Catheter ablation of electrical storm in a patient with left ventricular assist device A 66-year-old patient who had a left ventricular assist device (LVAD) implantation 6 years earlier was referred to our center for treatment of electrical storm. The patient had ischemic cardiomyopathy with severely reduced left ventricular ejection fraction (LVEF 20 %) on the basis of inferior and apical transmural myocardial scars and moderately reduced right ventricular (RV) function. The patient received a LVAD (HeartMate II, Thoratec Switzerland GmbH, Zürich, Switzerland) and an implantable cardioverter defibrillator (ICD) in 2007. In 2007, sustained ventricular tachycardias (VTs) were detected and the patient received oral chronic amiodarone medication. During the next few years the patient suffered from recurrent episodes of nonsustained VT and three to four sustained VTs per year, which were terminated with antitachy cardiac pacing (ATP). In 2010 he received eight ICD shocks. Programming was optimized with a higher number of ATP cycles. The patient suffered from recurrent dizziness, later attributed to VT episodes detected in the ICD monitor zone. After a temporary improvement of RV function, recurrent right heart decompensation occurred during the months before the present hospitalization. In September 2013 he was hospitalized because of dizziness, angina pectoris, and ICD shocks. He was referred to our center because of electrical storm [nine VTs, cycle length (CL) 300– 340 ms, eight shocks during 48 h]. On admission he presented with right heart decompensation and an ongoing slow VT [CL 490 ms, right bundle branch block (RBBB), left superior axis]. We decided to perform an early ablation.
Catheter ablation Ablation was performed with the patient under conscious sedation using propofol and midazolam. Oral anticoagulation was continued aiming at an INR between 2.0 and 2.5. After two right femoral vein punctures, an RV catheter and a transseptal sheath (Agilis NxT, St. Jude Medical, St. Paul, Minnesota, USA) were placed for insertion of the ablation catheter (. Fig. 1). The right femoral artery was punctured for invasive blood pressure measurement. LVAD flow was continued as before. With programmed stimulation from the RV catheter, we induced sustained VT with a CL of 340 ms, RBBB, and right superior axis. After termination of the tachycardia, substrate mapping was performed during sinus rhythm using the three-dimensional mapping system CARTO 3 (Biosense Webster Inc, Diamond Bar, USA; . Fig. 2). An inferior and an apical low-voltage (scar) zone (bipolar voltage
Anja Schade · Karin Nentwich · Thomas Deneke Klinik für Kardiologie II (Interventionelle Elektrophysiologie), Herz-und Gefäßklinik Bad Neustadt a.d. Saale, Germany
Catheter ablation of electrical storm in a patient with left ventricular assist device A 66-year-old patient who had a left ventricular assist device (LVAD) implantation 6 years earlier was referred to our center for treatment of electrical storm. The patient had ischemic cardiomyopathy with severely reduced left ventricular ejection fraction (LVEF 20 %) on the basis of inferior and apical transmural myocardial scars and moderately reduced right ventricular (RV) function. The patient received a LVAD (HeartMate II, Thoratec Switzerland GmbH, Zürich, Switzerland) and an implantable cardioverter defibrillator (ICD) in 2007. In 2007, sustained ventricular tachycardias (VTs) were detected and the patient received oral chronic amiodarone medication. During the next few years the patient suffered from recurrent episodes of nonsustained VT and three to four sustained VTs per year, which were terminated with antitachy cardiac pacing (ATP). In 2010 he received eight ICD shocks. Programming was optimized with a higher number of ATP cycles. The patient suffered from recurrent dizziness, later attributed to VT episodes detected in the ICD monitor zone. After a temporary improvement of RV function, recurrent right heart decompensation occurred during the months before the present hospitalization. In September 2013 he was hospitalized because of dizziness, angina pectoris, and ICD shocks. He was referred to our center because of electrical storm [nine VTs, cycle length (CL) 300– 340 ms, eight shocks during 48 h]. On admission he presented with right heart decompensation and an ongoing slow VT [CL 490 ms, right bundle branch block (RBBB), left superior axis]. We decided to perform an early ablation.
Catheter ablation Ablation was performed with the patient under conscious sedation using propofol and midazolam. Oral anticoagulation was continued aiming at an INR between 2.0 and 2.5. After two right femoral vein punctures, an RV catheter and a transseptal sheath (Agilis NxT, St. Jude Medical, St. Paul, Minnesota, USA) were placed for insertion of the ablation catheter (. Fig. 1). The right femoral artery was punctured for invasive blood pressure measurement. LVAD flow was continued as before. With programmed stimulation from the RV catheter, we induced sustained VT with a CL of 340 ms, RBBB, and right superior axis. After termination of the tachycardia, substrate mapping was performed during sinus rhythm using the three-dimensional mapping system CARTO 3 (Biosense Webster Inc, Diamond Bar, USA; . Fig. 2). An inferior and an apical low-voltage (scar) zone (bipolar voltage
