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A 47-year-old man with drug-resistant paroxysmal atrial fibrillation underwent left atrial (LA) catheter ablation. After sheaths were inserted into the LA using the Brockenbrough method, he complained of angina and developed ST-segment elevation in the II, III, aVF, V5, and V6 leads. Ventricular fibrillation (VF) occurred followed by ventricular tachycardia. The VF was successfully treated with direct current shock. Coronary angiography with isosorbide dinitrate showed neither spasm nor embolism in the coronary artery. The chest pain disappeared after 6 min with resolution of the ST-segment elevation. A summarized review of ST-segment elevation associated with transseptal puncture disclosed that ST-segment elevation is often found in inferior leads (87.5%), while concomitant bradyarrhythmia has been reported in 43.8% of patients. Our patient is the first recorded case with potentially lethal tachyarrhythmia. Although ST-segment elevation and VF is a rare complication associated with transseptal puncture, awareness of this complication is important.

A 47-year-old woman with Ebstein’s anomaly suffered from an out-of-hospital cardiac arrest caused by ventricular fibrillation. Electroanatomical activation mapping showed an atrialized right ventricle. Atrial electrocardiogram, normal atrioventricular node conduction delay, and ventricular electrocardiogram were confirmed in the right atrium. Relatively preserved ventricular amplitude was found in the septal wall. Based on these findings, a transvenous dual-chamber implantable cardioverter-defibrillator was implanted for the prevention of sudden cardiac death. The patient has fared well, without any lead malfunctions, lead dislodgement, or inappropriate shocks. Sufficiently high atrial and ventricular amplitudes were confirmed during 18 months of follow-up.

An implantation of a cardioverter-defibrillator was attempted in a 32-year-old man with atrial tachycardia, ventricular tachycardia and sinus node dysfunction. He had undergone a Senning operation and half closure of ventricular septal defect in order to correct a transposition of the great arteries. Cardiac catheterization revealed severe pulmonary hypertension and Eisenmenger syndrome. Prior knowledge of the complex cardiac anatomy obtained by magnetic resonance imaging helped in determining the suitable site for implanting the leads and planning the procedural strategy. With repletion of a large amount of saline and oral anticoagulation with warfarin, no complications related to thromboembolism occurred during a 10-month follow-up period.

Background: We investigated the efficacy and safety of strict voltage-based substrate mapping and radiofrequency catheter ablation (SV-substrate-map ablation) in patients with electrical storm. Methods and Results: SV-substrate-map ablation was performed in 15 patients suffering from multiple appropriate shocks (6.0 ± 3.8/day) from implantable cardioverter defibrillators (ICDs). Strict voltage criteria were defined as: non-arrhythmogenic areas, >0.6mV; low voltage areas, >0.1 to ≤0.6 mV; and scar, ≤0.1 mV. Using an electroanatomic mapping system, catheter ablation was performed at every possible arrhythmogenic region inside the low voltage areas. Further, we presented a review of the literature and investigated the published data on substrate-mapping guided ablation for electrical storm. After repeat endocardial ablation procedures in 4 patients and an epicardial approach in one, the targeted ventricular tachycardias (VTs) were successfully ablated, and the electrical storms were completely controlled in all. During a mean follow-up period of 801 ± 409 days, only one VT followed by an appropriate ICD shock was observed. No potential complications occurred during the procedure or follow-up. Our results were comparable or better than that of previous substrate-mapping guided ablation studies. Conclusion: SV-substrate-mapping ablation may be effective and safe for resolving serious clinical situations and prolonging the longevity of ICD devices in patients with electrical storms.

We describe a patient with nonischemic cardiomyopathy who underwent radiofrequency (RF) catheter ablation for a drug-refractory ventricular tachycardia (VT). RF ablation from a left ventricular (LV) endocardial site failed to eliminate the VT. Using a conventional ablation catheter with the temperature-controlled mode, RF ablation from the LV epicardium resulted in failed ablation because of low power due to a temperature limitation function. However, by using a pericardial pigtail catheter for manual infusion and removal of saline within the pericardial space, adequate energy could be delivered, and the ablation overlying the lowvoltage area successfully eliminated the VT.