Successful chemical ablation for intraventricular septal ventricular tachycardia-An alternative approach to the septal branch

Abstract

Trans-coronary ethanol ablation for ventricular tachycardia originating from the ventricular septum is effective, but there are cases with no septal perforator from left anterior descending artery. CT and angiography can reveal the optimal vessel.

Keywords: coronary computed tomography angiography; previous myocardial infarction; septal perforator; trans‐coronary ethanol ablation; ventricular tachycardia.

FIGURE 1

(A) Coronary computed tomography (CT; volume rendering) showing stents implanted in the left coronary artery. Two stents were implanted in the left anterior descending branch (LAD) in 2009 (a) and 2018 (b). Two stents were also implanted in the left coronary artery circumflex (c, d). (B) Left: 12‐lead ECG during sinus rhythm (SR). Right: 12‐lead ECG during ventricular tachycardia (VT). The patient had sustained monomorphic VT with a right bundle branch block and wide QRS on the inferior axis. (C) During SR, the HD grid showed a low voltage area at the middle of the left ventricular (LV) septal endocardium. (D) Observation of the LV endocardium with HD grid during VT showed the earliest potentials at the base of the LV septum.

FIGURE 2

(A) Irrigation catheter placed in the left ventricle, and HD grid placed in the right ventricle during ventricular tachycardia (VT). (B) The earliest VT potentials were almost the same during the use of the irrigation catheter and HD grid. (C) Pacing stimulation was performed at the earliest VT site from the left and right ventricles, and the morphology was more similar to VT in the left ventricle. (D) The RF energy was delivered in the left ventricular septal endocardium during VT.

FIGURE 3

(A) No vessels return to the base of the ventricular septum from LAD (red asterisk). (B) Coronary CT shows the HL branch (yellow star) and LAD. The septal perforator (white arrow) is seen at the base of the ventricular septum. (C) Ethanol injection into the septal perforator. A guiding catheter was introduced into the left coronary artery, and selective contrast injection was administered via a microcatheter into the septal perforator (white arrow) branching from the HL branch (yellow star). (D) The contrasts did not shunt (black arrow). (E) Ventricular premature contractions were observed before ethanol administration but were suppressed after ethanol administration.