"Rescue" ablation of electrical storm in arrhythmogenic right ventricular cardiomyopathy in pregnancy

Abstract

Background: Radiofrequency ablation (RFCA) became a treatment of choice in patients with recurrent ventricular tachycardia, ventricular fibrillation, and appropriate interventions of implanted cardioverter-defibrillator (ICD), however, electrical storm (ES) ablation in a pregnant woman has not yet been reported.

Case presentation: We describe a case of a successful rescue ablation of recurrent ES in a 26-year-old Caucasian woman during her first pregnancy (23rd week). The arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) was diagnosed 3 years earlier and several drugs as well as 2 ablations failed to control recurrences of ventricular tachycardia. RFCA was performed on the day of the third electric storm. The use of electroanatomic mapping allowed very low X-ray exposure, and after applications in the right ventricular outflow tract, arrhythmia disappeared. Three months after ablation, a healthy girl was delivered without any complications. During twelve-month follow-up there was no recurrence of ventricular tachycardia or ICD interventions.

Conclusions: This case documents the first successful RFCA during ES due to recurrent unstable ventricular arrhythmias in a patient with ARVD/C in pregnancy. Current guidelines recommend metoprolol, sotalol and intravenous amiodarone for prevention of recurrent ventricular tachycardia in pregnancy, however, RFCA should be considered as a therapeutic option in selected cases. The use of 3D navigating system and near zero X-ray approach is associated with minimal radiation exposure for mother and fetus as well as low risk of procedural complication.

Figure 1

Clinical PVC trigger of non-sustained VT in pregnant woman prior to intracardiac mapping (Lead V5 and V6 are disconnected). Slight different morphology of PVC (first QRS) as compared to VT can be noticed.

Figure 2

Low density, simplified electroanatomical mapping of RVOT (52 points). Yellow dot represent His position. Blue dot represent position of catheter where VT was located. Green dot represent point where PVC stopped and red dots represent additional bonus applications. Red area shows low voltage area (<1.5 mV).

Figure 3

Local activation mapping of PVC triggering fast VT from RVOT just before successful application. Local signal from distal tip of ablation catheter proceeded QRS during PVC over 25 msek. ECG speed - 100 mm/s.