Substrate Modification of Ischemic Scar in the Left Ventricle

An 85-year-old patient, known case of hypertension, diabetes mellitus, hypothyroidism, coronary artery disease, P/percutaneous transluminal coronary angioplasty, P/coronary artery bypass grafting, P/cardiac resynchronization therapy-D, heart failure with reduced ejection fraction (HFrEF), left ventricular (LV) ejection fraction = 30%, and paroxysmal atrial fibrillation, presented with two episodes of syncope in the emergency department. On device evaluation, the patient was found to have received appropriate therapies for ventricular tachycardia (VT)/ventricular fibrillation (VF) episodes despite of optimal medical therapy with metoprolol succinate extended release, amiodarone, and mexiletine. The patient was admitted and laboratory records were unremarkable except for raised N-terminal pro–b-type natriuretic peptide (NT-ProBNP) level of 10054 pg/mL. Following decongestive therapy, the patient was planned for VT substrate mapping using CARTO 3D mapping system. Echocardiography was suggestive of regional wall motion abnormalities and it ruled out LV apical clot. VT induction was not attempted as patient had previous episodes of hemodynamic unstable VT. The cutoff value bipolar voltage was set at 0.5 mV for densely scarred area. Scar homogenization was performed at sites with fractionated potentials and late potentials, as shown in Figure 1. VT was non-inducible with ventricular extrastimulations. The patient underwent procedure without any complication and was discharged after 2 days. The patient was asymptomatic and VT/VF free on 24 h Holter at follow-up at 2-, 6-, and 8-weeks post-procedure. Furthermore, NTProBNP also decreased to a level 800 pg/mL at follow-up.

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Figure 1:

(a) Fractionated potentials. (b) Late potentials. (c) Ablation tags.

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