Successful Substrate-Guided Ablation of Ventricular Tachycardia Storm in Acute Heart Failure Without Mechanical Circulatory Support

TL;DR

A patient with severe heart failure and dangerous heart rhythm was successfully treated with ablation without advanced support, using detailed mapping techniques.

Contribution

Demonstrates successful VT ablation in acute heart failure without mechanical circulatory support using substrate-guided mapping.

Findings

Substrate-guided mapping localized a critical isthmus in the left ventricle.

Ablation terminated VT and rendered it noninducible with tailored anesthesia.

Procedure was stable and effective using functional substrate mapping and limited intra-VT mapping.

Abstract

Ventricular tachycardia (VT) storm in advanced systolic heart failure carries high morbidity and mortality. Ablation is often performed with advanced imaging and mechanical circulatory support, which may not be available in resource-limited settings.

A 62-year-old man with ischemic cardiomyopathy (left ventricular ejection fraction: 25% to 30%) presented with recurrent monomorphic VT refractory to antiarrhythmic therapy, complicated by hemodynamic instability and multiorgan dysfunction. Mechanical circulatory support was not feasible. Substrate-guided mapping using voltage, late potentials, local abnormal ventricular activity, isochronal late activation mapping, and decrement-evoked potential mapping localized a critical isthmus in the basal posterior left ventricle. Ablation terminated VT and rendered it noninducible under monitored anesthesia care with norepinephrine and low-dose dobutamine.

Functional substrate mapping with limited intra-VT mapping and tailored anesthesia enabled procedural stability and successful VT ablation.

Substrate-guided mapping with individualized hemodynamic support can achieve safe, effective VT ablation in resource-limited settings.

Figures