Ablation of electrograms with an isolated, delayed component as treatment of unmappable monomorphic ventricular tachycardias in patients with structural heart disease
Angel Arenal, MD*,*,
Esteban Glez-Torrecilla, MD*,
Mercedes Ortiz, PhD*,
Julian Villacastín, MD*,
Javier Fdez-Portales, MD*,
Elena Sousa, MD*,
Silvia del Castillo, MD*,
Leopoldo Perez de Isla, MD*,
Javier Jimenez, MD* and
Jesus Almendral, MD*
* Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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figure 1 Diagram showing the approach to mapping and radiofrequency (rf) ablation of ventricular tachycardia (vt). e-idc = electrogram displaying isolated, delayed component; rvap = right ventricular apex pacing; sr = sinus rhythm.
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Figure 2 Three examples in which the E-IDCs were recorded only during RVA pacing. Four ECG surface leads are recorded, along with intracardiac electrograms from the His area, RVA, and left ventricle (LV) during RVA pacing and SR. Notice that in the three examples, during RVA pacing, a small and late component separated by an isoelectric line appears. This component is not evident during SR.
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Figure 3 Voltage map showing the location of the E-IDC area. This map during RVA pacing shows a right and inferior view of the septum and inferior walls of the left ventricle (LV) in a patient with ischemic heart disease. The color range represents the voltage amplitude. Red denotes dense scar, and gray denotes complete scar. Blue dots show sites where E-IDCs surrounded by complete scar were recorded. The arrows show the electrogram recorded at the entrance of the corridor (pink dot), at the E-LIDC site, and at the site where multiple components were recorded. Red dots denote the E-IDC sites where radiofrequency energy was delivered. (A) Clinical VT. (B) Pace map from the E-LIDC reproducing the VT morphology with a long S-QRS interval.
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Figure 4 Induction of VT from the RVA during the recording of E-ILDC. (A) Four ECG surface leads and intracardiac recordings from the His area, RVA, and left ventricle (LV) are recorded during RVA pacing. The introduction of two extrastimuli provoked the lengthening of the activation time of the E-LIDC and the induction of VT. The E-LIDC preceded the first VT beat and became mid-diastolic. (B) Voltage map showing all E-IDC sites of the area (blue dots).
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Figure 5 (A) Voltage map obtained during RVA pacing. The E-IDCs were recorded in the space located between the inferior and superior scars. (B) Activation map recorded during VT. The color index reveals the continuity between the earliest and latest activated areas typical of reentry. The E-IDC during RVA pacing and mid-diastolic electrogram of VT have the same morphology and are recorded at the same site. LV = left ventricle.
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