Between SCYLLA and CHARYBDIS: recurrent VT storm with intramural origin in a patient with LV thrombus and marked pericardial adhesions

Introduction: In patients with drug-refractory electric storm (ES), a condition associated with high mortality, successfull ablation has shown acute efficacy and long-term survival benefit. The outcomes could be limited by pericardial disease and/or the presence of LV thrombus. Cardiac sympathetic denervation (CSD) has been shown to reduce the burden of ICD shocks and VT storm in small studies.
Case presentation: A 62 years old man with non-is-chemic DCM with severe LV systolic dysfunction was admited for ES (103 adequate ICD therapies). Clinical VT (VT1) suggested epicardial origin and he was pre-viously diagnosed with LV apical thrombus. Epicardial ablation was not possible (pericardial adhesions). Endocardial bipolar voltage mapping with stereotaxis showed small scar areas whereas the unipolar map was highly suggestive for extensive scar, covering LV almost entirely. VT1 and another monomorphic VT (VT2) were made non-inducible after RF delivery at their endocardial exit points (good pace-mapping, but Stim-to-QRS=60ms). Postablation triple extrastimulus testing induced only polymorphic VT that was terminated by external shock. Next day the patient presented frequent NSVT episodes (morphologies, similar with VT2 but with a wider QRS, 20% on 24 h Holter) triggered by the smallest movement or emotion. Bilateral thoracic sympathectomy (T2-T4) was performed and ventricular arrythmias were completely supressed. At 1 year follow-up the patient reports only 3 isolated episodes of VT/VF (months apart) that responded to first ATP/shock while his heart failure symptoms are stationary.
Conclusions: Endocardial ablation was possible and safe in the presence of old LV thrombus especially with the stereotaxis soft catheter. Pericardial adhesions can be extensive and problematic even without previous cardiac surgery (miocarditis?). CSD can be life-saving in the setting of electric storm when other therapies have failed.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)