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Case Reports
. 2025 Aug 6;30(22):104655.
doi: 10.1016/j.jaccas.2025.104655.

Combined TAVR and Ventricular Tachycardia Ablation for VT Storm With Severe Aortic Stenosis

Tuna Ustunkaya  1 , Joseph A Quintana  2 , Meredith Kingeter  2 , Tiffany Hu  2 , Travis D Richardson  2 , William G Stevenson  2 , Angela M Lowenstern  2
Affiliations
Case Reports

Combined TAVR and Ventricular Tachycardia Ablation for VT Storm With Severe Aortic Stenosis

Tuna Ustunkaya et al. JACC Case Rep. .

Abstract

Objective: To describe the feasibility and clinical considerations of a simultaneous transcatheter aortic valve replacement (TAVR) and ventricular tachycardia (VT) ablation in a critically ill patient with severe aortic stenosis and VT storm.

Key steps: Preprocedural planning involved both electrophysiology and structural teams present. Transfemoral TAVR was performed using a Sapien S3 valve (Edwards Lifesciences) under general anesthesia with both transesophageal and transthoracic echocardiography guidance. While crossing the aortic valve into the left ventricle, VT occurred and was promptly cardioverted.We then transitioned to ablation of VTs, targeting their origin in the left ventricular scar. After the procedure, we monitored for recurrence of VT and potential device upgrade for heart block. Potential Pitfalls: Issues that can arise include hemodynamic instability during valve crossing and rapid pacing, risk of complete heart block, reinducibility of VT after valve implantation, and prolonged procedure time, which requires careful anesthetic and electrophysiologic planning.

Take-home messages: Combined TAVR and VT ablation is feasible and can effectively treat 2 life-threatening problems in high-risk patients. A team-based, individualized approach is essential for procedural success.

Keywords: ablation; aortic valve; stenosis; ventricular tachycardia.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Stevenson has received speaking honoria from Abbott, Johnson & Johnson, Biotronik, Boston Scientific, and Mediasphere; and research funding from Adagio and Varian Medical Systems. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Visual Sumamry
Visual Sumamry
Combined TAVR and VT Ablation in VT Storm
Figure 1
Figure 1
TTE Gradients TTE demonstrates severely reduced left ventricular ejection fraction (25%-30%), severely increased left atrial volume index, severely calcified mitral valve leaflets, and annulus with mild mitral regurgitation and mitral stenosis. The mean mitral stenosis gradient was 6 mm Hg at an heart rate of 73 mm Hg. TTE = transthoracic echocardiography.
Figure 2
Figure 2
VT Induced by Wire Crossing Into the Left Ventricle, Antitachycardia Pacing Accelerated the VT, and it was Subsequently Cardioverted VT = ventricular tachycardia.
Figure 3
Figure 3
Intracardiac Electrograms Obtained During TAVR (A) Second episode of VT before TAVR terminated by antitachycardia pacing from the ICD (B). Pacing at 180/min for 24 seconds during valve insertion did not induce VT. ICD = implantable cardioverter-defibrillator; TAVR = transcatheter aortic valve replacement; VT = ventricular tachycardia.
Figure 4
Figure 4
TAVR Placement A 29-mm Sapien S3 valve (Edwards Lifesciences) is deployed. TAVR = transcatheter aortic valve replacement.
Figure 5
Figure 5
Voltage Map of the Left Ventricle Showing Ablation Lesion Sites (Red Tags) A large area of septal low-voltage scar is present, extending inferiorly. Purple is normal voltage (>1.5 mv), and voltage decreases from blue to green to yellow to red.
Figure 6
Figure 6
TTE Gradients After TAVR and VT Ablation TTE demonstrates a roughly similar ejection fraction, with significant reduction in aortic gradients. No significant obstruction or paravalvular regurgitation was found. Doppler Velocity Index: 0.4. TAVR = transcatheter aortic valve replacement; TTE = transthoracic echocardiography; VT = ventricular tachycardia.
See this image and copyright information in PMC

References

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