Author + information
- Received May 14, 2018
- Accepted May 17, 2018
- Published online September 17, 2018.
- Jean-Marc Sellal, MDa,b,∗ (, )
- Isabelle Magnin-Poull, MDa,b,
- Alberto Battaglia, MDa,b,
- Darren Hooks, MD, PhDc and
- Christian de Chillou, MD, PhDa,b,d
- aDépartement de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France
- bINSERM-IADI U1254, Vandœuvre lès-Nancy, France
- cCardiology Department, Wellington Hospital, Wellington, New Zealand
- dUniversité de Lorraine, Nancy, France
- ↵∗Address for correspondence:
Dr. Jean-Marc Sellal, Département de Cardiologie, Hôpitaux de Brabois, 1, rue du Morvan, 54511 Vandœuvre lès Nancy, France.
- arrhythmogenic right ventricular cardiomyopathy
- epicardial ablation
- ventricular tachycardia
- ventricular tachycardia mapping
A 73-year-old patient with an arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) was referred for ventricular tachycardia (VT) ablation. The procedure was performed with a combined endocardial and percutaneous epicardial approach, using the CARTO3 mapping system. After the clinical VT was induced (cycle length 450 ms), its circuit was successfully mapped on both surfaces, each map showing a typical “figure-of-eight” re-entrant circuit as shown by Figure 1 and Online Video 1. Of utmost importance, the VT propagation wave fronts on both maps were perfectly synchronous.
The second RF application terminated VT after 29 s. After a total of 28 min of RF applications (endocardial only) across the VT isthmus, no VT was inducible anymore. One year later, the patient remains VT free.
ARVD/C is explained by the progressive replacement of cardiomyocytes by fibro-fatty tissue, with epicardial layers being first involved by this process. Therefore, an epicardial approach is often described as useful to access the VT circuits, with the claim that most VTs might be located epicardially in such patients. However, the rate of complications is much higher with an epicardial approach. In our patient, a direct epicardial approach would have managed to map the tachycardia and could have falsely concluded that the circuit was confined epicardially. The simultaneous endocardial and epicardial mapping of this VT illustrates—for the first time to our knowledge—that even in a “remodeled” ventricle, no shift between endocardial and epicardial activation may be observed. As a consequence, endocardial mapping may be considered first in VT occurring in ARVD/C patients, given that an efficient transmural ablation can be performed using this approach.
Dr. Sellal has a relationship with Biosense Webster. Dr. de Chillou has received consulting fees from Abbott; and lecture fees from Biosense Webster, Abbott, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received May 14, 2018.
- Accepted May 17, 2018.
- 2018 American College of Cardiology Foundation