Multidetector computed tomography-integrated ventricular tachycardia ablation in a post-ischemic patient with apical aneurysm and extensive dystrophic calcification

Figures

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  Figure 1. Multidetector computed tomography post-processing (left); multidetector computed tomography-derived left ventricular wall thickness 3D map highlighting the putative conducting channel (center); the clinical ventricular tachycardia morphology (right). 3D = 3-dimensional.

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  Figure 2. Pacing maneuvers at multidetector computed tomography-derived putative conduction channel confirming its correlation with protected critical isthmus of the tachycardia. Single extrabeat delivered at diastolic signal (DECANAV 1) shows local capture and effective ventricular tachycardia (VT) reset with concealed fusion (see surface electrocardiogram). Moreover, post-pacing interval (PPI) is almost equal to VT total cycle length (TCL) (ie, PPI – VT TCL < 30 ms, blue bars) and stimulus-QRS (S-QRS) interval is almost equivalent to local electrogram (EGM)-QRS interval (ie, S-QRS – EGM-QRS < 20 ms, green bars).

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  Figure 3. Electroanatomic endocardial bipolar voltage mapping with annotated the entry-conduction channel (CC) electrograms (EGMs) (black dots) and inner-CC EGMs (light blue dots); the white structure is the multidetector computed tomography-derived apical dystrophic calcification which has been segmented independently and merged with voltage mapping; note that scar voltage threshold has been set at <0.5 mV (A); radiofrequency ablation point (red dot) corresponding to the inner part of the multidetector computed tomography-derived putative channel determining ventricular tachycardia (VT) interruption (B); endocardial left ventricular activation mapping during VT showing the VT slow-conducting isthmus at the anterior apical septum and the fragmented mid-diastolic EGM at the ablation site (C). LAT = local activation time.

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  Figure 4. MDCT-derived LVWT reconstruction with complete lesion set at the end of the procedure (A); apical dystrophic calcification (white) with complete lesion set at the end of the procedure (B). Interestingly, no ablation targets were found within the apical calcium deposit. LAT = local activation time; LVWT = left ventricular wall thickness; MDCT = multidetector computed tomography.