Successful Substrate-Guided Ablation of Ventricular Tachycardia Storm in Acute Heart Failure Without Mechanical Circulatory Support

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  VISUAL SUMMARY. Successful Substrate-Guided VT Ablation Without Mechanical Support in Acute Heart Failure

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  Figure 1. Transthoracic Echocardiography Apical 4-chamber view showing dilated left ventricle with global hypokinesis and reduced left ventricular ejection fraction (25% by Simpson biplane method).

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  Figure 2. ECG Demonstrating Ventricular Tachycardia 12-lead ECG demonstrating monomorphic ventricular tachycardia at 141 beats/min with left bundle branch block–like morphology, left axis deviation, and QRS width 188 ms with intermittent capture beat. ECG = electrocardiogram.

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  Figure 3. Preprocedural Coronary Angiography and Chest X-Ray

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  Figure 4. Right and Left Ventricular Bipolar Voltage Map Proximal dominant RCA occlusion on coronary angiography correlated with a dense scar area (red) at the basal posterior septum on the endocardial voltage map of the left ventricle during sinus rhythm. RCA = right coronary artery.

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  Figure 5. Isochronal Late Activation Mapping (A) ILAM in sinus rhythm detected deceleration zones (DZs) at the posterobasal wall of the left ventricle. (B) ILAM with RV pacing at cycle length 500 ms detected diastolic potentials corresponding to the entrance of the VT isthmus. (C) ILAM with S2 RV pacing at cycle length 500 to 320 ms (VERP + 20 ms) detected diastolic potentials corresponding to the entrance of the VT isthmus. (D) Local activation map during VT detected a mid-diastolic signal in the same area as with ILAM with S1 and S2 RV pacing. (E) Biventricular activation mapping during VT showed the RV was only passively activated via breakout into the RV posterior basal septum. (F) Ablations terminated the VT, and the postablation map showed a consistent block over that line. ILAM = isochronal late activation mapping; RV = right ventricular; VERP = ventricular effective refractory period; VT = ventricular tachycardia.