Pushing the Limits

A 77-year-old man with a history of ischemic cardiomyopathy and apical aneurysm presented with a ventricular tachycardia (VT) storm that was refractory to multiple antiarrhythmic drugs. Transthoracic echocardiography revealed left ventricular ejection fraction of 15% and a well-defined layered thrombus. After discussing risks and benefits, the patient underwent VT ablation guided by intracardiac echocardiography. Electroanatomic mapping localized the critical VT isthmus to the middle portion of the ischemic scar. Clinical VT was successfully suppressed with ablation, and the patient was discharged with no acute complications. VT ablation in the presence of an intracavitary thrombus is an uncommon procedure due to the potential risk of thromboembolic events. Most reports in the literature consist of isolated cases or small case series. However, advancements in technology-specifically the use of intracardiac echocardiography and high-definition mapping systems-have expanded the possibilities for VT ablation. This approach offers a lifesaving alternative for patients experiencing VT storm that is unresponsive to traditional treatments.