The Ring of Fire – Substrate Isolation in Ischemic Heart Disease and Recurrent Ventricular Tachycardia

We present a case of a 79-year-old man with slow ventricular tachycardia (VT) storm and ischemic heart disease despite antiarrhythmic drug therapy, implantable cardioverter defibrillator (ICD), and two VT catheter ablations. He presented with stable ischemic heart disease and a large apical aneurysm along with a left ventricular ejection fraction of 30%. We performed catheter ablation in conscious sedation. After substrate-based mapping, we identified a large scar area in the region of the aneurysm. Only the cycle length of the clinical VT was known but not inducible. Two other VTs were inducible. As the slow VTs were not accessible through the ICD due to slow heart rate, we performed an encirclement of the whole scar tissue. After that, no VTs were inducible anymore and the patient remained free of symptomatic episodes thereafter. The best strategy in substrate-based ablation is still not clear. Prospective clinical trials are needed to identify the right strategy for the right patient.