Abstract
Postinfarct patients with malignant ventricular tachyarrhythmias (VTs) are prone to an increased risk for sudden cardiac death and implantation of an internal cardioverter-defibrillator (ICD) often is recommended. In cases where the VTs are incessant or refractory to medical treatment, disruption of the macro-reentry circuit, which represents the arrhythmogenic substrate for postinfarct VTs, is a major therapeutical goal for electrophysiologists. The precise identification of this underlying macro-reentrant circuit depends on conventional mapping techniques (i.e. diastolic potentials, entrainment) and more recently by a three-dimensional non-fluoroscopic electroanatomical mapping system (CARTO), which integrates anatomical and electrophysiological information to reconstruct a three-dimensional activation and propagation map of the relevant VT. This reports describes on a patient with recurrent, drug-refractory, hemodynamically stable monomorphic VTs on the basis of a 2-vessel coronary artery disease, reduced left ventricular ejection fraction, who was scheduled for coronary artery bypass graft operation combined with mitral valve replacement and reconstruction of the tricuspid valve. Preoperatively, the underlying mechanism of the VT was identified by CARTO mapping with a slow conduction zone and a wide exit site at the inferoapico-basal portion of the left ventricle. In close cooperation between the cardiologists and the surgeons the decision for a simultaneous ablation approach during the subsequent operation was made. Successful ablation of the VT using microwave energy was confirmed by non-inducibility of the VT in the perioperative electrophysiologic study. This case report highlightens the use of CARTO mapping to identify postinfarct VTs as well as the application of microwave energy as a useful tool to cure postinfarct ventricular arrhythmias.
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References
The Multicenter Postinfarction Research Group Risk stratification and survival after myocardial infarction. N Engl J Med 1983;309:331–336.
Moss AJ, Hall WJ, Cannon DS, Daubert JP, Higgs SL, Klein H, Levnie JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M. Improved survival with an implanted defibrillator in patients with coronary artery disease at high risk for ventricular arrhythmia. N Engl J Med 1996;335:1933–1940.
El-Sherif N. Arrhythmogenic substrates of ventricular arrhythmias. Implications for management. In:Saksena S, Luderitz B, editors. Interventional Electrophysiology:A textbock. Armonk NY:Futura Publishing 1976; 69–87.
de Bakker JM, van Capelle FJ, Janse MJ, Wilde AA, Coronel R, Becker AE, Dingemans KP, van Hemel NM, Hauer RN. Reentry as a cause of ventricular tachycardia in patients with chronic heart disease:Electrophysiologic and anatomic correlations. Circulation 1988;77:589–606.
Stevenson WG, Friedman PL, Sager PT, Saxon LA, Kocovic D, Harada T, Wiener I, Khan H. Exploring postinfarction reentrant ventricular tachycardia with entrainment mapping.J Am Coll Cardiol 1997;29:1180–1189.
Ezekowitz JA, Armstrong PW, McAlister FA. Implantable cardioverter defibrillators in primary and secondary prevention:A systemic review of randomized, controlled studies.Ann Intern Med 2003;138:445–452.
Morady F, Harvey M, Kalbfleisch SJ, El-Atassi R, Calkins H, Langberg JJ. Radiofrequency catheter ablation of ventricular tachycardia in patients with coronary artery disease. Circulation 1993;87:363–372.
Stevenson WG, Delacretaz E, Friedman PL, Ellison KE. Identification and Ablation of macroreentrant ventricular tachycardia with the CARTO electroanatomical maping system.Pacing Clin Electrophysiol 1998;21:1448–1456.
Kuck KH, Schlter M, Geiger M, Siebels J. Successful catheter ablation of human ventricular tachycardia with radiofrequency current guided by an endocardial map of the area of slow conduction.Pacing Clin Electrophysiol 1991;14:1060–1071.
Stevenson WG, Khan H, Sager P, Saxon LA, Middlekauf HR, Natterson PD, Wiener I. Identification of Reentry Circuit sites during catheter mapping and radiofrequency ablation of ventricular tachycardia late after myocardial infarction. Circulation 1993;88:1647–1670.
Knaut M, Tugtekin SM, Jung F, Matschke K. Microwave ablation for the surgical treatment of permanent atrial fibrillation- a single center experience. Eur J Cardio Thorac Surg 2004;26:742–746.
Lin JC. Catheter microwave ablation therapy for cardiac arrhythmias. Bioelectromagnetics 1999;4:120–132.
VanderBrink BA, Gilbride C, Aronovitz MJ, Lenihan T, Schorn G, Taylor K, Regan JF, Carr K, Schoen FJ, Homound MK, Estes NA 3rd, Wang PJ. Safety and efficiency of a steerable temperature monitoring microwave catheter system for ventricular myocardial ablation. J Cardiovasc Electrophysiol 2000;11:305–310.
Thomas SP, Clout FR, Deery C, Mohan A, Ross DL. Microwave ablation of myocardial tissue:The effect of element design, tissue coupling, blood flow, power, and duration of exposure on lesion size. J Cardiovasc Electrophysiol 1999;10:72–78.
Erdogan A, Grumbrecht S, Neumann T, Neuzner J, Pitschner HF. Microwave, irrigated, pulsed, or conventional radiofrequency energy source:Which energy source for which catheter ablation? Pacing Clin Electrophysiol 2003;26:504–506.
Gonska BD. New ablation techniques in ventricular tachycardia.Z Kardiol 2000;89(3):171–176.
Karolyi L, Spitzer SG, Geller L, Kiss O, Laszik A, Sotonyi P, Merkely B. Isthmus ablation with a novel microwave catheter in dogs. IEEE Eng Med Biol Mag 2005;24:45–50.
Schuetz A, Schulze CJ, Sarvanakis KK, Mair H, Plazer H, Kilger E, Reichart B, Wildhirt SM. Surgical treatment of permanent atrial fibrillation using microwave energy ablation:A prospective randomized clinical trial. Eur J Cardiothorac Surg 2003;24:475–480.
Venturini A, Polesel E, Cutaia V, Asta A, Mangino D, Moretti R, Terrini A, Zussa C. Intraoperative microwave ablation in patients undergoing valvular surgery:Midterm results. Heart Surg Forum 2003;6:409–411.
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Braun, M.U., Knaut, M., Rauwolf, T. et al. Microwave Ablation of an Ischemic Sustained Ventricular Tachycardia During Aortocoronary Bypass, Mitral Valve and Tricuspid Valve Surgery Guided by a Three-Dimensional Nonfluoroscopic Mapping System (CARTO). J Interv Card Electrophysiol 13, 243–247 (2005). https://doi.org/10.1007/s10840-005-2784-6
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DOI: https://doi.org/10.1007/s10840-005-2784-6