Aleksieva, Katia A.

Balabanski, Tosho L.

Dinov, Borislav B.

Protich, Mihail M.

Shalganov, Tchavdar N.

Traykov, Vassil B.

English

Via Medica Journals

www.cardiologyjournal.org 567IMAGES IN CARDIOLOGYCardiology Journal2008, Vol. 15, No. 6, pp. 567–568Copyright © 2008 Via MedicaISSN 1897–5593Address for correspondence: Tchavdar N. Shalganov, MD, Cardiology Department, National Heart Hospital, 65,Koniovitsa Street, 1309 Sofia, Bulgaria, tel: +359 2 92 11 356; fax: +359 2 822 31 88; e-mail: tchavdar.shalganov@gmail.comSubstrate-based catheter ablation in previouslyundiagnosed arrhythmogenic right ventriculardysplasia by means of an electroanatomicmapping system using cutaneous patchesTchavdar N. Shalganov, Vassil B. Traykov, Mihail M. Protich,Borislav B. Dinov, Tosho L. Balabanski, Katia A. AleksievaNational Heart Hospital, Sofia, BulgariaMagnetic navigation and mapping systemshave been used for electroanatomic voltage map-ping and substrate-based catheter ablation in ar-rhythmogenic right ventricular dysplasia/cardio-myopathy (ARVD/C) [1–3].The case is presented of a 24-year-old malepatient with recurrent drug-refractory sustainedmonomorphic ventricular tachycardia. The patienthad no previous medical history. He reported thathis grandmother had died suddenly at the age of45 years. The 12-lead ECG in sinus rhythm showedonly slight notching of the QRS in leads II, V2 andV3, with normal ending part and no T-wave abnor-malities. The transthoracic echocardiogram wasunremarkable. More than 21 000 ventricular pre-mature beats with 2 different morphologies wererecorded by 24-hour Holter monitoring. Catheterablation was performed using the EnSite NavX elec-troanatomic mapping system (St. Jude Medical, Inc.,St. Paul, MN, USA). During the procedure, onlyshort bouts of the clinical arrhythmia were induci-ble in the right ventricular (RV) apex with program-med electrical stimulation with up to 3 extrastimu-li. One sustained (but lasting less than 1 min) andseveral unsustained episodes of a second monomor-phic ventricular tachycardia with left bundle branchblock morphology were reproducibly induced in theRV outflow tract instead, with the same program-med stimulation pattern. At this point, a suspicionof the presence of undiagnosed ARVD/C was raised.It was not possible to perform activation mappingdue to the unsustained nature of the arrhythmia.Consequently, a three-dimensional voltage map ofthe RV in sinus rhythm was created. Areas of redu-ced bipolar voltage (< 1.5 mV) were found, locatedin the so-called triangle of dysplasia (Fig. 1A, B).An ablation line was created between the low volta-ge areas in the RV outflow tract and the lateral wall.Following the procedure, a positive signal-averagedECG was obtained. Biventricular angiography duringstable sinus rhythm (Fig. 1C–F) showed severe dif-fuse RV enlargement and hypokinesis, with almostakinetic RV inferior wall. Partial apical left ventri-cular (LV) involvement was found as well, but withnormal LV end-diastolic and end-systolic volumeindices, and an LV ejection fraction of 61%. These2 additional tests provided sufficient criteria fora definite diagnosis of ARVD/C. Repeat transthora-cic echocardiography, performed after the ablation,again described normal cardiac structure and func-tion, with normal LV volumes and ejection fractionof 66%. Fifteen months after the ablation the pa-tient was free of arrhythmia recurrence, while be-ing treated with previously ineffective antiarrhyth-mic drugs.Although electroanatomic voltage mapping isnot an acknowledged first-line tool for diagnosingARVD/C, it can support this diagnosis or raise eno-ugh suspicion for this entity. There are severalpublications about the use of the CARTO electroana-tomic mapping system in patients with ARVD/C[1–3]. However, we were able to find only one568Cardiology Journal 2008, Vol. 15, No. 6www.cardiologyjournal.orgreport about the use of the EnSite NavX mappingsystem in a patient with previously diagnosedARVD/C, in whom the voltage map was used notfor ablation, but only to check for a match betweenthe low voltage area and the magnetic resonanceimage [4]. In our patient, there were not any ECGor echocardiographic hints about the presence ofa structural heart disease. The possible presenceof ARVD/C was suspected only during the electro-physiologic study. This suspicion was based initiallyon the reproducible induction of a ventricular tachy-cardia morphologically different from the clinicalarrhythmia. Afterwards, it was reinforced by thevoltage map. The diagnosis was confirmed by addi-tional diagnostic tests, and was based on currentcriteria [5], namely the presence of late potentialson signal-averaged ECG, frequent ventricular extra-systoles on Holter monitoring, left bundle branchblock — type ventricular tachycardia, and severeRV dilation with partial LV involvement. TheEnSite NavX electroanatomic mapping system couldbe useful for substrate-based mapping and ablationin patients with ARVD/C.References1. Boulos M, Lashevski I, Reisner S, Gepstein L. Electroanatomicmapping of arrhythmogenic right ventricular dysplasia. J AmColl Cardiol, 2001; 38: 2020–2027.2. Corrado D, Basso C, Leoni L et al. Three-dimensional elec-troanatomic voltage mapping increases accuracy of diagnosingarrhythmogenic right ventricular cardiomyopathy/dysplasia. Cir-culation, 2005; 111: 3042–3050.3. Verma A, Kilicaslan F, Schweikert RA et al. Short- and long--term success of substrate-based mapping and ablation of ven-tricular tachycardia in arrhythmogenic right ventricular dyspla-sia. Circulation, 2005; 111: 3209–3216.4. Roux JF, Dubuc M, Pressacco J et al. Concordance between anelectroanatomic mapping system and cardiac MRI in arrhyth-mogenic right ventricular cardiomyopathy. Pacing Clin Electro-physiol, 2006; 29: 109–112.5. McKenna WJ, Thiene G, Nava A et al. Diagnosis of arrhyth-mogenic right ventricular dysplasia/cardiomyopathy. Br Heart J,1994; 71: 215–218.Figure 1. A. Electroanatomic voltage map of the right ventricle in anteroposterior projection; B. Electroanatomicvoltage map of the right ventricle in right lateral projection; C. Right ventricular diastole; D. Right ventricular systole;E. Left ventricular diastole; F. Left ventricular systole. Panels C–F: Ventricular angiography, right anterior obliqueprojection, 45° (C, D) and 30° (E, F).

Substrate-based catheter ablation in previously undiagnosed arrhythmogenic right ventricular dysplasia by means of an electroanatomic mapping system using cutaneous patches

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Substrate-based catheter ablation in previously undiagnosed arrhythmogenic right ventricular dysplasia by means of an electroanatomic mapping system using cutaneous patches

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