Successful ablation of an epicardial ventricular tachycardia by video-assisted thoracoscopy:

A 19-year-old female was referred to us for monomorphic premature ventricular contraction (PVC) and non-sustained monomorphic ventricular tachycardia. The patient had undergone three endocardial (EN) and two combined EN and epicardial (EP) ablation attempts. The 12-lead ECG showed a PVC with an RBBB morphology (Figure 1A). Echocardiography showed decreased left ventricular function (LVEF 42%). The site of earliest EN activation was localized at the postero-baso-lateral side of the left ventricle on EN mapping (Figure 1A). A fluoroscopically guided pericardial puncture was performed, but the needle was not advanced due to adhesions. Therefore, we decided to attempt minimally invasive approach to facilitate access to the target area. The chest was entered in the third interspace using a non-rib-spreading mini-thoracotomy with thorascopic assistance (Figure 1B and C). Under direct visualization, mapping with a cooled tip catheter was performed near the region of EN ablation catheter (Figure 1C). Pacing at this location produced greater than 90% pace-map match. After ablation and at 6-month follow-up, no further PVC was noted. Video-assisted thoracoscopic epicardial access may be feasible for patients with pericardial adhesions and have epicardial ventricular arrhythmias. The technique allows us to reach wide area at epicardium, we think that it may be a useful tool to ablate VTs/PVSs originating from all sites of the epicardium. The full-length version of this report can be viewed at: http://www.escardio.org/communities/EHRA/publications/ep-case-reports/Documents/Successful-ablation-of-an-epicardial.pdf.