PMC9726845_01
Presenting EKG in WCT (a) with asterisks in lead aVL and III indicating possible intermittent p waves suggestive of atrio-ventricular dissociation consistent with monomorphic VT and sinus rhythm with 1st degree AV block following cardioversion (b).
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The patient's initial electrocardiogram (EKG) demonstrated possible atrioventricular association with intermittent p waves that did not correspond with QRS complexes, raising suspicion for monomorphic VT [Figure 1(a)]. Following cardioversion, the patient was in sinus rhythm with a first-degree atrioventricular (AV) block [Figure 1(b)].
CMR. 3-Chamber cine images in diastole (a) and systole (b) demonstrate a thinned, aneurysmal, and dyskinetic basal to mid inferolateral wall (yellow arrows). Increased signal intensity on T2-weighted STIR imaging in the mid inferolateral wall (blue arrow, c) is consistent with myocardial edema. Transmural LGE (red arrow, d) within the basal to mid inferolateral wall is consistent with replacement fibrosis.
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On CMR cine images, the basal to the mid inferolateral wall was thinned, aneurysmal, and dyskinetic [Figure 2(a) and (b)].
(a) Sinus rhythm voltage map of the LV with bipolar voltage demonstrating a small area of reduced voltage (red/green) in the basal inferolateral wall, corresponding with the aneurysm. (b) Sinus rhythm voltage map of the LV with unipolar voltage demonstrating a larger area of reduced voltage (green) in the basal inferolateral wall, corresponding with the aneurysm. (CARTO, Biosense Webster, Inc.).
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Sinus rhythm voltage mapping of the left ventricle (LV) demonstrated a small area of reduced bipolar voltage in the basal inferolateral LV, corresponding to the aneurysmal region on CMR [red/green region, Figure 3(a)]. Unipolar mapping of this area revealed a larger region of reduced voltage (< 8.27 mV) [green region, Figure 3(b)], corroborating the epicardial substrate seen on CMR.
Sinus rhythm voltage mapping of the epicardial substrate, with a large area of low voltage (red) over the aneurysm. (CARTO, Biosense Webster, Inc.).
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Endocardial radiofrequency ablation (RFA) was performed, followed by epicardial mapping (Figure 4) and epicardial RFA, resulting in both core isolation and VT non-inducibility.