Impact of Septal Radiofrequency Ventricular Tachycardia Ablation

W e present the case of a 38-year-old woman with no past medical history and structurally normal heart with recurrent drug-refractory septal ventricular tachycardia (VT).Despite treatment with flecainide, celiprolol, and sotalol, she experienced breakthrough episodes of VT (Figure 1B).She had undergone 5 failed attempts at VT ablation.She was therefore referred for a further attempt at ablation.Cardiac multidetector computed tomography and late gadolinium enhancement (LGE) MRI were performed before VT ablation.MRI demonstrated nontransmural subendocardial LGE on either side of the septum, which corresponded to previous ablation sites (Figure 2A, Movie I in the online-only Data Supplement). Consecutive Unipolar Ablation ProceduresGiven the multiple failed attempts of endocardial ablation, we used a simultaneous endocardial and epicardial approach.VT was not inducible despite the use of isoproterenol and atropine.The ablation site was then targeted based on substrate mapping and pacemapping.Epicardial mapping did not show any abnormal voltage areas, and pacemap did not match the VT morphology.Endocardial mapping was then performed and radiofrequency energy was delivered at sites with good pacemaps (40 W, Thermocool Smarttouch, Biosense Webster) on the left and right ventricular midseptum.Radiofrequency delivery (40 W, 15g of contact force) at the right ventricular septum resulted in a steam pop after 34 seconds.A postprocedural MRI demonstrated the presence of a septal intramural hematoma without transmural scar (Figure 2B). DisclosuresDrs Jaïs, Haïssaguerre, Hocini, and Sacher have received lecture fees