Bidirectional ventricular tachycardia in ischemic cardiomyopathy during ablation

Figures

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  Figure 1. Clinical ventricular tachycardia is shown with pacing from the mapping catheter during ventricular tachycardia demonstrating entrainment with near-concealed fusion and measurements demonstrating that the distal bipole of the ablation catheter was near the exit site of a protected isthmus. ECG = electrocardiogram; EGM = electrogram; PPI = postpacing interval; TCL = tachycardia cycle length.

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  Figure 2. Second ventricular tachycardia (VT2) that occurred after the first radiofrequency application was delivered. VT2 exhibited a shorter but regular alternating cycle length associated with alternating morphology on the surface electrocardiogram and near-field electrogram.

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  Figure 3. Proposed circuit: we postulate that the clinical ventricular tachycardia (VT1) suppressed the wavefront exit of second VT (VT2) via concealed retrograde penetration. By the time VT1 exits, its wavefront (represented by solid arrows) collides and blocks the exit sites for VT2, leading to preferential manifestation of VT1 despite having a longer tachycardia cycle length. When the first radiofrequency (RF #1) at the VT1 exit site resulted in termination, VT2 was able to exit from the superior and inferior exit sites without collision with the antidromic wavefront of VT1. This allowed the manifestation of “bidirectional” VT2 (represented by dashed arrows). Another RF application (RF #2) was applied to the adjacent site to RF #1, the common isthmus of both superior and inferior exit sites for VT2, resulting in the termination of VT2. TCL = tachycardia cycle length.