Extracorporeal Membrane Oxygenation–Assisted Ablation of Extremely Refractory Purkinje Ventricular Fibrillation

Figures

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  Figure 1. 12-Lead Electrocardiogram of the Initiation of Ventricular Fibrillation The site of origin was suspected to be the left posterior fascicle toward the apex given the right bundle morphology, superior axis, and early precordial transition.

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  Figure 2. Intracardiac Echocardiography (ICE) Image With ICE Catheter in the Mid-Right Atrium Visualizing the Inflow Outflow View Visualizing Soft Thrombus (Blue Arrows) on the Aortic Valve NCC = noncoronary cusp; RCC = right coronary cusp; RVOT = right ventricular outflow tract; TV = tricuspid valve.

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  Figure 3. A 3D Representation of Electroanatomic Maps Revealing the Site of Early Activation of the Clinical PVC in LAO and Left Lateral Views Mapping of the initiation of ventricular fibrillation with the mapping catheter septal to the posteromedial (inferoseptal) papillary muscle (arrow) identifying fractionated signals of interest on the right panel. Anterolateral papillary muscle (arrow head) and mitral valve (MV). LAO = left anterior oblique; PVC = premature ventricular contraction.

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  Figure 4. A 3D Representation of Electroanatomic Maps Revealing the Site of Early Activation of the Clinical PVC in the LAO View Radiofrequency (RF) ablation at the site of earliest activation of the PVC close to the posteromedial (inferoseptal) papillary muscle (arrow) producing fascicular ventricular tachycardia from the left posterior fascicle. Anterolateral papillary muscle (arrow head) and mitral valve (MV). LAO = left anterior oblique, PVC = premature ventricular contraction.

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  Figure 5. High-Density Activation Mapping of Conduction Through the Fascicular System (Blue Arrows) in RAO and LAO Views in the 3D Mapping System Identifying the LAF and LPF LAF = left anterior fascicle; LAO = left anterior oblique; LPF = left posterior fascicle; MV = mitral valve.

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  Figure 6. A Final Representation of the Lesion Set in RAO and LAO Views in the 3D Mapping System Achieving a “De-Networking” Effect of the Purkinje-Myocardial System Mitral valve (MV), anterolateral (superolateral) papillary muscle (arrow head), posteromedial (inferoseptal) papillary muscle (arrow). LAO = left anterior oblique.