left ventricle ( lv ) remodeling and development of lv aneurysms after myocardial infarction ( mi ) lead to increased lv volumes , reduced lv ejection fraction ( lvef ) , and subsequent congestive heart failure ( chf ) 1 , 2 . surgical ventricular reconstruction ( svr ) is able to reduce lv volumes and improve lvef , yet the impact on morbidity and mortality is controversial and a high perioperative risk as well as postoperative malignant ventricular tachycardias ( vt ) have been reported 3 , 4 . recently , interventional strategies have been introduced to treat these highrisk patients 5 . the less invasive ventricular enhancement ( live ) technique using the reviventtc ( transcatheter)system ( bioventrix inc . , san ramon , ca ) is able to exclude lv aneurysms and restore lv volumes similar to svr by performing an offpump interventional procedure 6 , 7 . catheter ablation ( ca ) has evolved into an accepted treatment option for patients suffering from scarrelated vt 8 , 9 . to the best of our knowledge , we report on the first case of ca after livebased lv restoration and subsequently development of frequent vt . a 77yearold male with a history of chf ( new york heart association class iiiiv ) and anterior lv aneurysm after mi due to left anterior descending artery occlusion in 10/2000 was subjected for livebased lv restoration . to exclude progression of coronary artery disease , the patient underwent a successful mitraclipimplantation for severe mitral regurgitation in 06/2014 and a single lead icd was implanted for primary prevention in 02/2014 . no episode of vt or ventricular fibrillation ( vf ) was detected and no antitachycardial pacing ( atp ) or icdshock therapy was documented before the live procedure . the following preinterventional lv parameters were measured by angiography : enddiastolic volume ( edv ) : 593 ml , endsystolic volume ( esv ) : 545 ml , lvef : 8% . 1 ) . in total four pairs of anchors were placed and lv parameters were improved as the following : edv : 442 ml , esv : 377 ml , lvef : 15% . no periprocedural complications occurred . on the next day the patient developed sustained vt ( cycle length : 420 msec , right bundle branch block ( rbbb ) , inferior axis ) with subsequently induced cardiogenic shock . the patient was initially cardioverted via external defibrillator and intravenous administration of amiodarone 1000 mg / day was started . although the cycle lengths of vt was prolonged after administration of 9000 mg of amiodarone , the patient still frequently suffered from recurrent sustained and nonsustained vt . principle of the procedure ; prior ( a ) and after ( b ) lv restoration . mc , mitraclip ; rvlead , right ventricularlead of icd ; rv , right ventricle ; lv , left ventricle . the ca was performed 10 days after lv restoration and was conducted under endotracheal intubation and intravenous anesthesia without additional lvassist device . lv mapping was conducted via a combined antegrade transseptal and retrograde transaortic approach utilizing a threedimensional electroanatomical ( ea ) mapping system ( carto 3 system , biosense webster inc . , diamond bar , ca ) and a 8f , 3.5 mm irrigatedtip catheter ( navistar thermocool , biosense webster ) 10 . during mapping two different vt morphologies ( vt1 and vt2 ) external cardioversion was performed twice to restore sinus rhythm due to unstable hemodynamic status during vt . in total 213 mapping points were acquired identifying a large anterior scar , which presented as low amplitude ( < 1.5 mv bipolar voltage ) and/or abnormal electrograms ( fig . the ablation catheter was accidentally advanced into a residual part of the previously excluded lv aneurysm , which was not completely excluded 10 days after lv restoration . with pacemapping the entrance site of vt1 ( cycle length : 520 msec , rbbb , inferior axis ) was found anteromedial superior , whereas the exit site was identified anterolateral inferior at the ea scar border zone . irrigated radiofrequency ( rf ) current was delivered in the powercontrolled mode with a maximum power of 40w and a flow rate of 20 ml / min . via antegrade approach 8 rf applications ( total duration of 703 sec ) were performed to generate a linear lesion across the slow conduction zone resulted in prolongation and termination of vt1 ( fig . 3 ) . afterward vt2 ( cycle length : 600 msec , rbbb , superior axis ) was reproducibly induced . the best pacemap ( 9/12 ) of vt2 was located at the anteromedial apex . utilizing two rf applications via retrograde approach ( total duration : 217 sec ) afterward no vt was inducible via electrical programmed stimulation and burst pacing during a waiting period of 60 min . the patient was discharged after 10 days and freedom of any symptoms and no evidence of vt recurrence were observed . pacemapping of vt1 ( cl = 520 msec , right bundle branch block , inferior axis ) . ( a ) pacemapping with continuous reduction in stimulusqrs intervals . points ( i : red , ii : blue , iii : gray ) represent the corresponding locations within the electroanatomical map ( b ) . entrance and exit site a small residual aneurysm was found during mapping of the left ventricle ( white lines ) . ( i = red , ii = blue , iii = gray ) represent corresponding pacemapping locations . ( c , d ) corresponding angiographic images presenting the sight of ablation ( antegrade transseptal approach ) . ac , ablation catheter ; cs , coronary sinus catheter ; mc , mitraclip ; rvlead , right ventricularlead of icd . pacemapping and ablation of vt2 ( cl = 600 msec , right bundle branch block , superior axis ) . ( d , e ) corresponding angiographic images presenting the sight of ablation ( retrograde transaortic approach ) . ac , ablation catheter ; cs , coronary sinus catheter ; mc , mitraclip ; rvlead , right ventricularlead of icd . the ca was performed 10 days after lv restoration and was conducted under endotracheal intubation and intravenous anesthesia without additional lvassist device . lv mapping was conducted via a combined antegrade transseptal and retrograde transaortic approach utilizing a threedimensional electroanatomical ( ea ) mapping system ( carto 3 system , biosense webster inc . , diamond bar , ca ) and a 8f , 3.5 mm irrigatedtip catheter ( navistar thermocool , biosense webster ) 10 . during mapping two different vt morphologies ( vt1 and vt2 ) external cardioversion was performed twice to restore sinus rhythm due to unstable hemodynamic status during vt . in total 213 mapping points were acquired identifying a large anterior scar , which presented as low amplitude ( < 1.5 mv bipolar voltage ) and/or abnormal electrograms ( fig . the ablation catheter was accidentally advanced into a residual part of the previously excluded lv aneurysm , which was not completely excluded 10 days after lv restoration . with pacemapping the entrance site of vt1 ( cycle length : 520 msec , rbbb , inferior axis ) was found anteromedial superior , whereas the exit site was identified anterolateral inferior at the ea scar border zone . irrigated radiofrequency ( rf ) current was delivered in the powercontrolled mode with a maximum power of 40w and a flow rate of 20 ml / min . via antegrade approach 8 rf applications ( total duration of 703 sec ) were performed to generate a linear lesion across the slow conduction zone resulted in prolongation and termination of vt1 ( fig . 3 ) . afterward vt2 ( cycle length : 600 msec , rbbb , superior axis ) was reproducibly induced . the best pacemap ( 9/12 ) of vt2 was located at the anteromedial apex . utilizing two rf applications via retrograde approach ( total duration : 217 sec ) afterward no vt was inducible via electrical programmed stimulation and burst pacing during a waiting period of 60 min . the patient was discharged after 10 days and freedom of any symptoms and no evidence of vt recurrence were observed . pacemapping of vt1 ( cl = 520 msec , right bundle branch block , inferior axis ) . ( a ) pacemapping with continuous reduction in stimulusqrs intervals . points ( i : red , ii : blue , iii : gray ) represent the corresponding locations within the electroanatomical map ( b ) . entrance and exit site a small residual aneurysm was found during mapping of the left ventricle ( white lines ) . ( i = red , ii = blue , iii = gray ) represent corresponding pacemapping locations . ( c , d ) corresponding angiographic images presenting the sight of ablation ( antegrade transseptal approach ) . ac , ablation catheter ; cs , coronary sinus catheter ; mc , mitraclip ; rvlead , right ventricularlead of icd . pacemapping and ablation of vt2 ( cl = 600 msec , right bundle branch block , superior axis ) . ( d , e ) corresponding angiographic images presenting the sight of ablation ( retrograde transaortic approach ) . ac , ablation catheter ; cs , coronary sinus catheter ; mc , mitraclip ; rvlead , right ventricularlead of icd . we are presenting a case report of ca after livebased lv restoration and subsequently development of vt . no vt or vf was observed for > 18 month under icd surveillance until lv restoration while 1 day after the procedure the patient developed vt . we suggest most likely the vt was induced through lv restoration , for example , due to mechanical compression of the scar border zone . comparing to data after svr 11 ; ca after interventional livebased lv restoration was successfully performed via a combined antegrade and retrograde approach suggesting this treatment strategy to be possibly safe and feasible . however , as recently described for the parachute device the target area of vt ablation may be covered by the device itself and therefore not reachable for endocardial ca 12 . therefore , it should be taken into consideration whether patients who are planned for an interventional or surgical lv restoration should be evaluated for vt ablation prior procedure . in these patients an electrophysiological examination including programmed stimulation could possibly detect whether sustained monomorphic vts could be induced prior lv restoration . in clinical practice , programmed stimulation was not performed due to limited survival with the very poor lv function . furthermore , a preinterventional ea mapping could guide future lv restoration procedures to precisely detect scar area and border zone . in clinical practice , the number of patients with severe chf due to ischemic cardiomyopathy and the utilization of interventional treatment options are increasing 13 . this case report is presenting one way to successfully treat patients with postprocedural frequent vt . kh kuck received research grants from biosense webster , stereotaxis , prorhythm , medtronic , edwards , cryocath , and is a consultant to st .
key clinical messagethe reviventtcsystem is able to restore lv volumes in patients with severe ischemic cardiomyopathy . 
 we are presenting a case report of successful implantation of the reviventtcsystem , but postprocedural development of sustained vt . 
 this case report is presenting one way to successfully treat patients with postprocedural frequent vt .