John Kamel ZarifLecturer of cardiologyAin-Shams University

Case presentation by

A 60 years old male with past history of inferior wall MI 10 years ago had presented to our CCU at the Demerdash Hospital by recurrent wide complex tachycardia for which he had received DC shocks for cardioversion in every attack.

The tachycardia ECG had RBBB with extreme axis

Resting ECG was completely normal

His echocardiography revealed normal EF of 60% and small akinetic basal inferior and basal posterior segments only

Coronary angiography had revealed borderline 60% lesion in a big D1

Stress TC99 cardiac scan revealed normal uptake at all myocardial segments with no element of ischemic burden.

ICD implantation was scheduled but because of lack of resources had been delayed

Patient had pulmonary fibrosis so he was kept on sotalol medical therapy but unfortunately the attacks become recurrent and unstable.

So EPS was planned by 3D CARTO system

Resting ECG

Sotalol was stopped 3 days before EPS

1st we tried to induce the VT … but a lot of problems we had faced:

1- 5 different VTs morphology occurred and was interchanging

2- most of the VTs causing haemodynamic compromize (HR was 220 260 bpm)so DC shocks were needed

3- VTs were resistant to shock (VT storm)

Axis: superior -90 superior -90 superior -60 extreme +180 inferior +90Transition: V4 V6 V2 V2 V1

Patient status was deteriorating due to low perfusion state.. so …

We decided to give IV anti arrhythmic drugs both IV Xylocaine and IV loading Amiodarone . To maintanie sinus rhythm.

Then we started to create voltage map for further substrate mapping ablation protocol

Pace map 2

Pace map 1

One of the VTs was stable with acceptable BP so had allowed us for rapid activation map combined with entrainment mapping

Good entrainment site with PPI within 30 msec. from TCL

Stimulus – QRS = Diastolic potential - QRS

Bad entrainment

End of VT during ablation

2 lines of ablation at lateral and septal edges of the scar

At the end of procedure no inducible VT Procedure time about 4 hours

Follow up for 4 months no recurrence without anti-arrhythmic treatment

THANK YOU