Hybrid Surgical Ablation of Recurrent Ventricular Tachycardia in a Patient With High-Risk Brugada Syndrome

Figures

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  Figure 1. Case Report Timeline Timeline of the case from first discovery of Brugada syndrome (Brs) in 2007 until most recent follow-up visit in 2021. Numbers on the lower part of the illustration are number of ventricular tachycardia/ventricular fibrillation (VT/VF) episodes during the year; ∗VT/VF followed by implantable cardioverter-defibrillator (ICD) discharge. RVOT = right ventricular outflow tract; VATS = video-assisted thoracoscopic surgery.

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  Figure 2. Implantable Cardioverter-Defibrillator Recording of Monomorphic Ventricular Tachycardia Episode Documented recurrence of monomorphic ventricular tachycardia 6 years after index procedure.

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  Figure 3. Preoperative Electrocardiogram Brugada pattern type 1 present on leads V1, V2.

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  Figure 4. Left-Sided Thoracoscopy Camera port installed in IV intercostal space, 2 functional ports installed in II and VI intercostal spaces.

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  Figure 5. Video-Assisted Thoracoscopic Ablation Procedure (A) Multipolar grid catheter placed on the anterior right ventricular outflow tract through thoracoscopic port. (B) Ablation on the right ventricular outflow tract with use of unipolar RF ablation probe.

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  Figure 6. Slow Conduction on the Right Ventricular Outflow Tract: Fragmented Potentials Long (104 ms), low-voltage, fragmented potentials, aligned with QRS complex, recorded with multipolar catheter placed on the anterior right ventricular outflow tract, a typical finding on patients with Brugada syndrome.

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  Figure 7. Preablation Invasive Mapping Invasive epicardial activation map created using Ensite Precision System. Red areas showing earliest activation. Blue colors represent areas of slowed conduction. (Left) Baseline map showing delayed conduction over the anterior right ventricular outflow tract (RVOT). (Right) Channels B2-B3, C2-C3, D2-D3 showing long low-voltage fragmented potentials on the RVOT, typical of patients with Brugada syndrome. Postablation invasive mapping is inaccurate because impedance changes after insertion of first thoracoscopic port.

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  Figure 8. Preablation and Postablation Noninvasive Mapping (Left) Noninvasive activation map before and after ablation. Red areas show earliest activation. Blue colors represent areas of slowed conduction. (Far left) the earliest activation is on the anterior right ventricular outflow tract (RVOT) (small red area) and lateral RVOT is characterized by slow conduction (scar from previous ablation) blue area behind the red spot. Postablation activation is homogenous with no areas of early activation or slow conduction on the RVOT. (Right) Preablation and postablation voltage maps; violet area represents scar tissue, postablation map shows completeness of lesion area on the anterior RVOT.