Transapical access for catheter ablation of left ventricular tachycardia in a patient with mechanical aortic and mitral valve prosthesis

Trans-apical catheter ablation of ventricular tachycardia in a patient with metallic aortic and mitral valves

We present a patient with a history of heart failure and metallic aortic and mitral valves surgeries, who required ablation for a drug-refractory left ventricular tachycardia. But the metallic valves prohibited the insertion of catheters via retrograde or via trans-septal approaches. Therefore, we decided to perform catheter ablation by direct left ventricle puncture through a minithoracotomy. The arrhythmia was successfully ablated via of trans-apical approach and did not recur at six months follow-up.

Ablation of ventricular tachycardia by direct left ventricle puncture through a minithoracotomy after double valve replacement: a case report and literature review

We herein describe a 33-year-old woman with a mechanical aortic and mitral valve who developed repetitive monomorphic ventricular tachycardia with unstable hemodynamics. Catheter ablation by direct puncture at the left ventricular apex through a minithoracotomy successfully terminated the ventricular tachycardia, which had originated from the apical-septal endocardium in the left ventricle, despite the hindrance to routine access. No procedure-related complications or recurrence of the clinical ventricular tachycardia developed during a 66-month follow-up, demonstrating that endocardial ablation through direct cardiac cavity puncture can be considered in select cases.

Ventricular arrhythmias in nonischemic cardiomyopathy

Nonischemic cardiomyopathies (NICMs) are composed of variable disease entities, including primary and secondary cardiomyopathies. Determining the etiology of NICM provides pivotal roles of not only the understanding of the individual pathogenesis, but also the clinical management, such as risk stratification, pharmacological treatment, and intervention therapies. Despite the diverse causes of NICM, these cases mostly require clinical attention owing to progressive myocardial injury, resulting in ventricular dysfunction and heart failure. The interaction between the diseased ventricular substrates and systemic/neurophysiological factors contributes to the cornerstones responsible for ventricular arrhythmogenesis and sudden cardiac death (SCD). Prevention of SCD and diminishing ventricular tachyarrhythmias are the important mainstays for the management of NICM patients. Given the understanding of the abnormal ventricular substrates and advancement of navigation systems, radiofrequency catheter ablation (RFCA) has become an adjunctive or alternative strategy for NICM patients who experience drug-refractory ventricular tachycardias (VTs). Successful ablation can frequently be achieved at the expense of an epicardial intervention. A recent study has proven the survival benefits for NICM patients who are free from recurrent VTs after a successful RFCA, regardless of the New York Heart Association (NYHA) functional class status or left ventricular ejection fraction. Additionally, recent evidence has highlighted the better delineation of a diseased myocardium through the incorporation of cardiovascular magnetic resonance imaging (CMRI) and 3D mapping systems, which can facilitate the identification of critical ventricular arrhythmogenic substrates in NICM patients.