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Introduction The efficacy of stereotactic body radiation therapy (SBRT) as an alternative treatment for recurrent ventricular tachycardia (VT) is still unclear. This study aimed to report the outcome of SBRT in VT patients with nonischemic cardiomyopathy (NICM). Methods The determination of the target substrate for radiation was based on the combination of CMR results and electroanatomical mapping merged with the real-time CT scan image. Radiation therapy was performed by Flattening-filter-free (Truebeam™) system, and afterward, patients were followed-up for 13.5±2.8 months. We analyzed the outcome of death, incidence of recurrent VT, ICD shocks, anti-tachycardia pacing (ATP) sequences, and possible irradiation side-effects. Results A total of 3 cases of NICM patients with anteroseptal scar detected by CMR. SBRT was successfully performed in all patients. During the follow-up, we found that VT recurrences occurred in all patients. In one patient, it happened during a 6-week blanking period, while the others happened afterward. Re-hospitalization due to VT only appeared in one patient. Through ICD interrogation, we found that all patients have reduced VT burden and ATP therapies. All of the patients died during the follow-up period. Radiotherapy-related adverse events did not occur in all patients. Conclusions SBRT therapy reduces the number of VT burden and ATP sequence therapy in NICM patients with VT, which had a failed previous catheter ablation. However, the efficacy and safety aspects, especially in NICM cases, remained unclear. This article is protected by copyright. All rights reserved.

Background Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited condition which predominantly affects young people, characterized by fibrofatty replacement of the right ventricle. It is also commonly being underdiagnosed, so that the role of imaging is imperative to confirm diagnosis of ARVC patient. Case Summary A 57-year-old man presented with palpitation, syncope and chest pain. The symptoms had begun since 3 month prior to hospital admission with no family history of premature sudden death. He had been hospitalized 3 times before due to palpitation. Electrocardiogram (ECG) revealed ventricular tachycardia with LBBB morphology and superior axis. Patient was undergoing 100 Joule cardioversion, and the ECG post-cardioversion showed sinus rhythm with inverted T-wave in inferior and anterior leads. Echocardiography revealed enlargement and reduced function of right ventricle (RV). Coroangiography revealed nonsignificant stenosis coronary artery disease. Cardiac MRI showed dyssynchrony RV contraction, reduced RV ejection fraction Discussion Late clinical presentation of ARVC is rare, thus it should be included in the differential diagnosis when treating older patient with ventricular tachyarrhythmia. This case highlights the importance of imaging, either with echocardiography and cardiac MRI to confirm the diagnosis of ARVC as the potential cause sudden cardiac death.

Implantable cardioverter defibrillator shocks are common with catheter ablation procedures being increasingly used to minimize recurrent ventricular tachycardia (VT). The purpose of the review is to provide an update on approaches to identify critical portions of VT circuits. VT ablation has evolved from a surgical approach to a percutaneous minimally invasive approach. Pre-procedural planning including the use of cardiac MRI can provide valuable information about the underlying substrate. Mapping of the VT circuit with multipolar catheters and improved detection of slow conduction zones in sinus rhythm have reduced procedural time, decreased the need to map in VT, and facilitated improved procedural success. In this review, we revisit the four principle techniques for mapping ventricular tachycardia: activation mapping, entrainment mapping, pace mapping, and substrate mapping. We highlight recent enhancements in these techniques.

AIMS: The aim of this study was to determine whether revascularisation of an infarct-related artery chronic total occlusion (IRA-CTO) has a modulatory effect on myocardial scar composition. METHODS AND RESULTS: This is a unique, first-time report of three consecutive patients presenting with myocardial scar-related recurrent ventricular tachycardia (rVT) on a background of ischaemic cardiomyopathy. Electro-anatomic mapping of the left ventricular endocardium was performed before and immediately after IRA-CTO percutaneous coronary intervention (PCI) to assess for changes in scar composition and size. There were substantial percentage reductions in the low voltage area of scar compared to baseline after IRA-CTO PCI (Patient 1: −12.8%, Patient 2: −27.0%, and Patient 3: −15.3%). Interval remapping ≥6 months after the index procedure demonstrated extensive net reductions in all areas of myocardial scar (Patient 1: dense scar =−7.5%, border zone scar =−54.9%, low voltage area =−32.7%, and Patient 2: dense scar =−38.6%, border zone scar =−59.6%, low voltage area =−51.7%). Patient 3 declined interval remapping but has remained free of rVT at one-year follow-up. CONCLUSIONS: IRA-CTO PCI may positively modify the size and composition of myocardial scar associated with rVT in the context of ischaemic cardiomyopathy.

Background Recurrent ventricular tachycardia (VT) can occur after left ventricular assist device (LVAD) implantation. In this case, medical treatment might be insufficient. We report a case of a left-sided thoracoscopic sympathectomy as a feasible treatment escalation in intractable VT. Case report A 72-year-old patient underwent an internal cardioverter defibrillator (ICD) implantation as primary prophylaxis for VTs in the setting of staged heart failure therapy. Afterwards, due to a progressive dilative cardiomyopathy he underwent a minimal-invasive LVAD implantation (HeartWare, Medtronic). After an uneventful minimal-invasive LVAD-implantation the patient was discharged to a rehabilitation program. However, after 7 weeks he developed recurrent VTs which were successfully terminated by ICD shocks deliveries leading to severe discomfort and frequent hospitalizations. Eventually, the patient was admitted with an electrical VT storm. Successful endocardial catheter ablation of all inducible VTs were performed combined with multiple rearrangements of his oral antiarrhythmic medication. However, all these treatments could not suppress further occurrence of VTs. After an interdisciplinary discussion the patient agreed to a left-sided video-assisted thoracoscopic sympathectomy. After a follow up of 150 days the patient was free from VTs apart from one short event. Conclusion We believe video-assisted thoracoscopic sympathectomy might be a surgical treatment option in patients with intractable recurrent VTs after catheter ablation of VT reentrant substrate even after minimal-invasive LVAD implantation.

Stereotactic body radiotherapy (SBRT) has been suggested as a promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias (VTs) in patients with structural heart disease. This case series is the first postmortem immunohistochemical analysis of morphologic changes in the myocardium early and late after SBRT. The present findings are in line with experimental observations on apoptosis followed by fibrosis. This may explain why the effect of SBRT on VT is not predominantly immediate. Together with observation of early recurrences after SBRT for VT, these data suggest that this strategy may have rather delayed antiarrhythmic effects.

Introduction: The autonomous system plays an important role as a trigger of cardiac arrhythmias. Cardiac sympathetic denervation (CSD) achieved by stellate and proximal thoracic ganglia resection has been reported as an alternative approach for the management of ventricular arrhythmias (VA) in structural heart disease (SHD) patients. Insufficient data regarding Chagas Disease (ChD) is available. Methods: Patients who underwent CSD for better management of ventricular arrhythmias (VA) in SHD, mainly ChD, in a single tertiary center in Brazil were evaluated for safety and efficacy outcomes. Results: Between June 2014 and March 2020, fourteen patients (age 59±7.5, 85% male, mean ejection fraction 30.5±7.9%) were submitted to left or bilateral CSD. In a median follow-up time of 143 (Q1: 30; Q3: 374) days, eight patients (57,2%) presented VT recurrence. A significant reduction in the median burden of ventricular arrhythmias comparing six months before and after procedure (10 to 0; p=0.004). For the nine ChD patients, the median burden of appropriate therapies was also reduced (11 to 0; p=0.008). There were two cases of clinically relevant pneumothorax and three cases of transient hemodynamic instability, but no direct procedure-related deaths occurred. Additionally, there was no long-term adverse events, Conclusion: CSD is safe and seems to be effective in reducing the burden of VT/VT storm in SHD patients, including ChD patients. Randomized trials are needed to clarify its role in the management of these patients.

Lipomatous metaplasia in chronic postmyocardial infarction scars is a common and underappreciated finding seen in histopathology and cardiac MRI. Evidence suggests that lipomatous metaplasia is capable of altering the electroconductivity of the myocardium leading to re-entry pathways that are implicated in the pathogenesis of postmyocardial infarction arrhythmogenesis. We report a case of a patient who presented with non-sustained ventricular tachycardia and was found to have lipomatous metaplasia of a prior myocardial infarct-related scar.

Pheochromocytoma occasionally engenders catecholamine-induced hypertension crisis. Pheochromocytoma is clinically identified in 0.1%–5.7% of patients with neurofibromatosis type 1 (NF1), which is 10 times more frequently than in healthy individuals. This report describes a case of newly diagnosed NF1 presenting with pheochromocytoma crisis, with severe electrolyte depletion and deteriorating recurrent ventricular tachycardia storm. Characteristic skin lesions such as café-au-lait macules and neurofibromas contributed to the diagnosis of NF1 and pheochromocytoma. No recurrence of electrolyte depletion was found after the adrenalectomy. Primary care physicians must distinguish the characteristic skin lesions of NF1, such as café-au-lait macules and neurofibromas and recognise the risk for pheochromocytoma.

We report a case of cardiac intramural arteriovenous malformations (AVMs) misdiagnosed as hypertrophic cardiomyopathy and presented as life-threatening ventricular arrhythmia storm that was successfully controlled by cardiac sympathetic denervation. A 46-year-old male patient with an implantable cardioverter-defibrillator was admitted for recurrent ventricular tachycardia requiring repeated shock refractory to antiarrhythmic drugs. Although the patient was previously diagnosed with hypertrophic cardiomyopathy, multimodality imaging studies showed large left ventricular intramural AVMs, potentially representing arrhythmogenic substrates. Life-threatening ventricular arrhythmia storm, which could not be controlled by radiofrequency catheter ablation and therapeutic hypothermia. However, cardiac sympathetic denervation surgery successfully controlled the ventricular arrhythmia storm.

Ventricular arrhythmias are one of the leading causes of death in patients with a prior myocardial infarction. Implantable cardioverter-defibrillators (ICDs) are very effective in the prevention of sudden cardiac death but the risk of recurrence remains an issue since defibrillation does not alter the underlying substrate. Recurrent ICD shocks are distressing and are associated with an increase in mortality. Catheter ablation is an effective treatment for recurrent ventricular tachycardia in these patients, particularly when antiarrhythmic therapy produces side effects or is ineffective. This paper reviews the underlying mechanisms of VT in patients with a prior myocardial infarction, and the indications, strategies and outcomes of catheter ablation.

Primary cardiac tumors are very rare and may have variable clinical presentation, depending on their nature and location. Recent WHO classification divides them into benign, tumors of uncertain biologic behavior, germ cell tumors, and malignant tumors.1 Sustained or incessant ventricular tachycardia (VT) has been reported relatively infrequently in association with cardiac tumors.2, 3, 4 Interestingly, patients with large fibromas in the pediatric population were at the highest risk, with VT occurring in more than 60% of cases.4 In adults, this type of tumor is very sporadic.5 We present a case of a patient with an intermediate cardiac fibroma triggering recurrent VTs that necessitated the whole spectrum of therapeutic approaches, including stereotactic radiosurgery.

The first onset of cardiac event of long QT syndrome (LQTS) was at young age and caused by emotional or physical triggers. We presented a 64-year-old woman who experienced recurrent ventricular arrhythmia after hemodialysis initiation because of end-stage renal disease. Persistent prolonged QTc interval and diagnosis of inherited LQT2 were missed at her first 3 years of hemodialysis. The patient was beta-blocker nonresponder for ventricular arrhythmias suppression and experienced multiple ICD discharge. We reported an inherited LQT2 case with uncommon clinical manifestations and the successful experience of mexiletine use in such a patient.

Background: Data characterizing structural changes of arrhythmogenic right ventricular (RV) cardiomyopathy are limited. Methods: Patients presenting with left bundle branch block ventricular tachycardia in the setting of arrhythmogenic RV cardiomyopathy with procedures separated by at least 9 months were included. Results: Nineteen consecutive patients (84% males; mean age 39±15 years [range, 20–76 years]) were included. All 19 patients underwent 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average 385±177 points per map; range, 93–847 points). Time interval between the initial and repeat ablation procedures was mean 50±37 months (range, 9–162). No significant progression of voltage was observed (bipolar: 38 cm 2 [interquartile range (IQR), 25–54] versus 53 cm 2 [IQR, 25–65], P =0.09; unipolar: 116 cm 2 [IQR, 61–209] versus 159 cm 2 [IQR, 73–204], P =0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase, 28%; 206 mL [IQR, 170–253] versus 263 mL [IQR, 204–294], P P =0.006; unipolar: Spearman ρ, 0.5743, P =0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure. Conclusions: In patients with arrhythmogenic RV cardiomyopathy presenting with recurrent ventricular tachycardia, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent ventricular tachycardias are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with arrhythmogenic RV cardiomyopathy who have progressive RV dilation.

Catheter ablation for polymorphic ventricular tachycardia and ventricular fibrillation (PMVT/VF) may target triggering premature ventricular contractions (PVCs). Targeting ventricular scar has also been suggested, but data are limited.The purpose of this study was to characterize the electrophysiological findings and ablation outcomes for patients with PMVT/VF and structural heart disease (SHD) compared to those with idiopathic VF.Data from 32 consecutive patients (13 idiopathic VF, 19 SHD) with recurrent PMVT/VF who underwent catheter ablation were reviewed.A low-voltage area of myocardial scar was present in 15 of 19 patients with SHD. Sustained monomorphic ventricular tachycardia (SMVT) associated with scar was inducible and targeted in 8, 3 of whom had previous SMVT episodes separate from PMVT/VF episodes and 5 had no history of SMVT. Triggering PVCs were identified in 11 patients and arose from an area of endocardial scar in 6. Only scar ablation was performed in 8 patients who did not have triggering PVCs. All idiopathic VF patients underwent PVC ablation only. During a median of 540 days, 74% of SHD patients and 77% of idiopathic VF patients were free of recurrence, including 75% of those with only PVC ablation, 86% of those with scar plus PVC ablation, and 63% of those with only scar ablation.Patients with recurrent PMVT/VF and SHD often have a low-voltage scar associated with PVCs or inducible SMVT, which may also be the substrate for PMVT/VF. When present, substrate ablation targeting scar is a reasonable option for treatment of PMVT/VF even if PVCs are absent.

Background The comparative efficacy of antiarrhythmic drug (AAD) therapy vs ventricular tachycardia (VT) ablation in arrhythmogenic right ventricular cardiomyopathy (ARVC) is unknown. Objective We compared outcomes of AAD and/or β-blocker (BB) therapy with those of VT ablation (with AAD/BB) in patients with ARVC who had recurrent VT. Methods In a multicenter retrospective study, 110 patients with ARVC (mean age 38 ± 17 years; 91[83%] men) with a minimum of 3 VT episodes were included; 77 (70%) were initially treated with AAD/BB and 32 (29%) underwent ablation. Subsequently, 43 of the 77 patients treated with AAD/BB alone also underwent ablation. Overall, 75 patients underwent ablation. Results When comparing initial AAD/BB therapy (n = 77) and VT ablation (n = 32) after ≥3 VT episodes, a single ablation procedure rendered 35% of patients free of VT at 3 years compared with 28% of AAD/BB-only–treated patients (P = .46). Of the 77 AAD/BB-only–treated patients, 43 subsequently underwent ablation. For all 75 patients who underwent ablation, 56% were VT-free at 3 years after the last ablation procedure. Epicardial ablation was used in 40/75 (53%) and was associated with lower VT recurrence after the last ablation procedure (endocardial/epicardial vs endocardial-only; 71% vs 47% 3-year VT-free survival; P = .05). Importantly, there was no difference in survival free of death or transplantation between the ablation- and AAD/BB-only–treated patients (P = .61). Conclusion In patients with ARVC and a high VT burden, mortality and transplantation-free survival are not significantly different between drug- and ablation-treated patients. These patients have a high risk of recurrent VT despite drug therapy. Combined endocardial/epicardial ablation is associated with reduced VT recurrence as compared with endocardial-only ablation.

We present a case of a 66-year-old patient with myocardial infarction with ST-segment elevation, multivessel coronary artery disease and recurrent ventricular tachycardia after percutaneous coronary angioplasty. Patient was transferred to our Clinic to consider implantable cardioverter-defibrillator implantation. On the basis of the presented case, authors point out difficulties in making decisions concerning management of patients with persistent ventricular arrhythmias complicating acute coronary syndrome.

Epicardial radiofrequency catheter ablation is currently considered as the therapeutic option of choice in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) and recurrent ventricular tachycardia (VT). We hypothesised that inducibility of VT may guide the ablation strategy and thereby affect long-term results. Additional epicardial ablation was only performed if VT were still inducible after thorough endocardial ablation. The objective was to examine an inducibility-guided ablation approach by comparing the long-term results between endocardial and epi-endocardial radiofrequency catheter ablation of VT in a large cohort of patients with ARVD/C. We studied from our ARVD/C registry (70 patients in total, 48 males, age 53.2 ± 14.0) 45 patients (64.3% of all patients) who underwent catheter ablation of VT. All patients received endocardial VT ablation. After endocardial ablation, 24 patients (53.3%) remained inducible. Additional epicardial ablation was performed in 22 patients (48.9%). After ablation, non-inducibility was achieved in overall 38 patients (84.4%). During a mean follow-up of 31.1 ± 27.4 months, 13 patients in each group (59.1% after endo- and epicardial ablation, 56.5% after endocardial ablation) remained free from VT recurrence (P = 0.862). An inducibility-guided catheter ablation strategy of VT in patients with ARVD/C prevents unnecessary epicardial ablation and may therefore be considered as an alternative to primary combined endo- and epicardial ablation.

Herein, we report a 47-year-old woman with ischemic cardiomyopathy who underwent ablation therapy due to an electrical storm without any triggers. The voltage mapping in sinus rhythm with the Rhythmia system and Orion catheter displayed several LAVAs in and around the anteroapical scar area. Although the patient did not tolerate the induced clinical ventricular tachycardia, which was reproductively induced, 35-second-mapping in the scar zone with the Orion catheter demonstrated the VT circuit with the critical isthmus. This report shows the possibility of the new ultra-high density mapping system in a specific ischemic VT patient.

Severe LV dysfunction and advanced age are associated with VT recurrence after catheter ablation in patients with post-infarction drug-refractory VT. We present retrospective analysis of long-term outcome after single and repeat VT ablation procedures in patients with ischemic heart disease.Patients with recurrent VT post infarction who underwent catheter ablation between 2006 and 2017 in Isala Heart Centre were retrospectively analyzed. Univariate and multivariate analysis were used to identify predictors of arrhythmia recurrence post ablation. Patients were allocated to subgroups based on LVEF: severe (30%), moderate (30-40%) and mild LV dysfunction (41-51%) and analyzed with log rank test.A total of 144 patients were included. Two years VT free survival after a single procedure was 56.6% with median follow-up 46 [17-78] months. Recurrence of VT postablation wash high among patients with an old anteroseptal MI and LVEF30% with multiple morphologies of inducible VTs, indicating an extensive and complex substrate. Patients who underwent repeat ablations (27.1%) had significant more often LV aneurysms (20.5% vs. 7.6%, p = .03) and electrical storms (38.5% vs. 21.9%, p = .04). VT free survival was higher in patients with LVEF 41-51% compared to LVEF30% (71.4% vs. 47.8%, p = .01). In multivariate analysis, LVEF30% (vs 41-51%) was an independent predictor of arrhythmia recurrence (HR = 2.16, CI 1.15-4.06, p = .02).In patients with ischemic VT, success rate of ablation was highest among patients with preserved LV function and recurrent VT and ES was highest among patients with severe LV dysfunction after single and multiple ablation procedures.

Cardiac fibromas are rare tumours of the heart. We present a case of cardiac fibroma in a four-year-old child in view of rarity of the case and success achieved in its management. The child had presented with a history of intermittent palpitations. Electrocardiography (ECG) showed monomorphic Ventricular Tachycardia (VT). She was initially managed with intravenous Metoprolol and Amiodarone infusion but had recurrent VT. Echocardiography revealed a mass in the apical septum. A Contrast Enhanced Computed Tomography (CECT) showed a homogeneous mass involving the anterolateral and apical aspect of interventicular septum causing expansion of the septum and indentation and compression of both ventricles. The tumour was approached through median sternotomy under Cardiopulmonary Bypass (CPB). The adventitia over the exposed part of the tumour was incised and the tumour was dissected out of the interventricular septum. A bovine pericardial patch was used to close the septal defect. Most of the small tumours dispersed around Left Anterior Descending Artery (LAD) were excised. The patient was weaned off CPB easily. In the postoperative period, Amiodarone infusion was continued with no recurrence of arrhythmias. Histopathology revealed classical features of fibroma. The child is stable and is on outpatient follow-up. Our patient had a huge fibroma and we could successfully resect it avoiding need for transplant. We hereby conclude that in children with a huge intracardiac fibroma involving almost a complete cardiac chamber, success can be achieved through resection and reconstruction in selected cases and the need for transplant may be obviated.

We report the case of a 2-month old infant who experienced recurrent sustained ventricular tachycardia (VT) in a structurally normal heart. Resting electrocardiogram (ECG) showed wide QRS with a complete right bundle branch bloc (RBBB) morphology. There was no family history of syncope or sudden death, but the ECGs of the father and the brother showed incomplete RBBB with negative T waves on V1 lead. This case seems to fit well with the newly defined entity of Brugada-like syndrome with a highly suspected genetic underlying disposition.

Introduction: Opiate dependence is among the main contributors to diseases worldwide, imposing heavy costs on the healthcare system. As an established approach, substitution therapy by methadone has been long considered as the most effective therapeutic method. Case Presentation: Herein, we present the case of a 40-year-old man, who was referred to the hospital with complaints of sudden and transient loss of consciousness and a history of opiate dependence under methadone therapy, showing recurrent ventricular tachycardia and resistant torsade de pointes. Conclusions: Poisoning is among the major adverse effects of methadone use, which involves different systems of the body, including the cardiovascular and respiratory systems. Furthermore, effective drugs on QT interval show interferences. Therefore, it is suggested to incorporate relevant recommendations in the new version of the national opiate-dependence therapy protocol.

International audience; Radiofrequency catheter ablation is an important therapeutic option for patients with recurrent ventricular tachycardia (VT). The procedure aims at cauterizing regions of the ventricle. A good knowledge of anatomical structures and tissues properties can improve procedure safety and efficacy. This work aimed at analysing the feasibility of a workflow based on multimodal image integration to assist the intervention. We focused here on a model including myocardial thickness and fibrosis extracted from late gadolinium enhanced MRI (LGE-MRI) sequence, and left ventricular anatomy segmented from multiphase computed tomography (CT). The produced model can be imported within Carto-3® system (Biosense Webster Inc, Diamond Bar, CA), the software used during the ablation procedure. Four patients cases have been included in this preliminary study. The four produced patient specific models have been validated by a clinician, and two of them have been integrated within Carto-3® system and used during the intervention. © 2017 IEEE Computer Society. All rights reserved.

Cardiac sarcoidosis is a common presentation of the disease but with variable manifestations; delay in diagnosis and treatment can have significant consequences. While benign in some, it can also be a life-threatening disorder causing sudden death. We describe a case of primary cardiac sarcoid with

Erdheim-Chester disease (ECD) is a rare histiocytosis characterized by multiorgan involvement. Cardiac involvement can manifest as myopericardial infiltration, valvular disease, and conduction abnormalities. A 72 year old man with ECD presented with bradycardia-induced polymorphic ventricular

Viability imaging with FDG-PET has the unique ability to differentiate between scar and hibernating myocardium and is typically used to guide revascularization strategies. We present a case of refractory ventricular tachycardia (VT) where FDG-PET viability imaging successfully guided management. 61