Successful chemical ablation of refractory ventricular tachycardia from the left ventricular summit using the double balloon technique with chronic total occlusion percutaneous coronary intervention techniques

Figures

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  Figure 1. A: Twelve-lead electrocardiographic morphology showing ventricular tachycardia (VT). B: A decapolar catheter was advanced to the anterior interventricular vein (arrow). C: The earliest ventricular activation during the VT preceded the QRS onset by 28 ms at the distal tip of the decapolar catheter.

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  Figure 2. A: The tip of the ablation catheter was advanced to the basal anterior segment of the left ventricle near the decapolar catheter. B: Activation mapping demonstrated the centrifugal activation pattern with the earliest activation close to the earliest decapolar catheter. C: The endocardial potentials recorded close to the earliest decapolar catheter preceded QRS onset by 34 ms, which also showed the QS morphology in a unipolar electrogram. D: The radiofrequency energy was delivered to the earliest site using an irrigation catheter, which could transiently terminate the sustained ventricular tachycardia, but not eliminate it completely. E: Ice-cold saline infused through the infusion lumen of the decapolar catheter decreased the frequency of premature ventricular contractions.

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  Figure 3. A, B: Retrograde coronary venogram of the great cardiac vein (GCV) depicted collateral flow to the anterior interventricular vein (AIV) overlying the left ventricular summit (arrow). C, D: The guidewire could proceed to the collateral vessel from the AIV and eventually into the guiding catheter (GC). A microcatheter was passed retrogradely over the guidewire and finally advanced to the GC. E: Schematic of the approach. The guidewire was removed and exchanged for a 330 cm RG3 guidewire to thread through the Y-connector of the internal mammary artery (IMA) GC. The RG3 guidewire was manually engaged into an introducer needle antegradely inserted into the Y-connector of the hemostatic system. F: Schematic of the approach. Another guidewire was inserted through an 8.5F sheath from the femoral vein and advanced to the collateral vessel via the AIV. G: Two over-the-wire (OTW) balloons were inserted into the collateral vessel via the GC and 8.5F sheath (arrow). H: The proximal and distal portions of the collateral vessel were occluded using OTW balloons inflated at 4 atm. Contrast medium (1.0 mL) injected into the proximal balloon demonstrated contrast stagnation in the occluded area.…