Pulsed-field ablation in a patient with ventricular arrhythmia storm receiving mechanical circulatory support

Figures

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  Figure 1. Catheter positioning. Depicted are representative images from the case. A: Fluoroscopy with the Impella and pulsed-field ablation catheter in the left ventricle. In the right atrium, right ventricle, and pulmonary artery, respectively, are an ECMO cannula, quadripolar catheter, and Swan-Ganz catheter. A subcutaneous ICD coil is also seen overlying the heart. B: Intracardiac echocardiography image showing the relationship of catheters within the left ventricle, with the Impella at the apical septum and PFA catheter at the apex. C: Mapping point from the anterior wall during VT with representative electrocardiograms shown. ECMO = extracorporeal membrane oxygenation; ICD = implantable defibrillator; PFA = pulsed-field ablation; VT = ventricular tachycardia.

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  Figure 2. Lesion set, electrocardiographic changes, and pre and post maps. Depicted are the lesion set, electrocardiographic changes, and pre and post maps. A: Left ventricle with shadows of the PFA catheter indicating the site of lesions. B: Baseline and intraprocedural electrocardiogram with ST changes observed. C: Baseline isochronal activation map. D: Post-ablation isochronal activation map. PFA = pulsed-field ablation.

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  Figure 3. Apical core histology. Panels depict histological specimens from the apical core. A: (H&E staining, 100× magnification) healing myocardial injury approximately 3 weeks in age. B to D: Masson trichrome staining at 20×, 20×, and 100× magnification, respectively. B: Large area of fibrotic scar. C: Recently ablated patches of myocardium within fibrotic scar, with darker staining and volume loss (red arrow) of myocytes that died at the time of ablation compared with healthy myocardium near the epicardium (yellow arrow). Scale bar of 1 mm is included. D: Nuclei preservation in the ablated zone.