PMC5436767_01
Twelve-lead electrocardiograms during VT (A). The VT manifests a left bundle branch block configuration and an inferior axis with a QS pattern in the v1 lead. The Pace mapping from the RV of the RV-LV hinge point (B). The latter matches the clinical VT perfectly, with short pacing-QRS intervals (40 ms). Black lines are limb leads and blue lines are precordial leads.. Abbreviations: LV, left ventricle; RV, right ventricle; VT, ventricular tachycardia.
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A 41-year-old female patient with a history of aborted sudden death was admitted to our hospital for the third time due to repeated episodes of monomorphic VT (135 bpm, left bundle branch block morphology) and frequent implantable cardioverter defibrillator (ICD) shocks (Figure 1). Furthermore, pace mapping from the RV side of the RV-LV hinge point matched the clinical VT, with short pacing QRS intervals (40 ms; Figure 1B).
Focal aneurysm (arrow head) at the anterior left ventricle on echocardiography (A). Transmural extension of delayed gadolinium enhancement (arrows) on cardiac magnetic resonance imaging (B).
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Echocardiography and cardiac MRI revealed a focal aneurysm in the anterior left ventricle (LV) due to cardiac sarcoidosis (Figure 2A and B). Meanwhile, a short axis view of the delayed gadolinium enhancement image revealed myocardial scarring extending to the upper part of the ventricular septum across the aneurysm (Figure 2B).
Voltage maps showing a localized low voltage area in the left ventricular aneurysm in LAO (A, with RV) and RAO (B, without RV) view. The voltage maps of the successfully ablated site and ablation catheters in LAO (C) and RAO (D).. Abbreviations: LAO, left anterior oblique; LV, left ventricle; LV ABL, left ventricular ablation catheter; RAO, right anterior oblique; RV, right ventricle; RV ABL, right ventricular ablation catheter.
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The voltage map revealed a low voltage area (<1.5 mV) consistent with the anterior focal aneurysm (Figure 3A and B). THERMOCOOL; Biosense Webster) was placed at the anterior aneurysm in the LV and the second irrigation catheter (CoolFlex, Saint Jude Medical) at the RV side of the RV-LV hinge point (Figure 3C and D). The RV ablation catheter was connected as a return electrode to the RF generator instead of to a dispersive patch.