VT Ablation Using Brachial Artery Access and Integrated Cardiac Imaging

Ischemic scar mediated VT ablation has evolved to being performed through the femoral vein and artery with either transseptal or retrograde access left ventricle (LV). However, in some patients severe peripheral arterial disease (PAD), via may not be possible. We present a case of patient recurrent ischemic ICD who had undergone two Fem-Fem surgeries was felt n appropriate candidate for vascular by surgery. After discussion surgery, we right brachial cutdown approach, used integrated (inHEART) imaging assist procedural mapping ablation. To our knowledge, this is first reported using an irrigated catheter, inHEART imaging. The 72 year old man history smoking, CAD status post MI, CABG, cardiomyopathy, PAD, despite on sotalol. recently second bypass prosthetic graft 6 months earlier. His EF echocardiogram 31%. He switched amiodarone briefly, but did wish long term wished proceed reviewing elected artery. Cardiac CT specifically processing inHEART. Right surgery (Figure 1a) EP lab arm based operator preference. Anesthesia provided moderate sedation. Initially, thought from would more consistent usual workflow when performing side patient. A short 9 French sheath placed vein, SR0 8.5 1b) under direct visualization. Through sheath, decapolar (Decanav Biosense Webster) catheter advanced RV. 3-D Mapping CS, bundle, SVC were allow registration previously acquired map. Significant difficulty encountered approaching LV artery, as approach favored wire, move across aortic arch down descending aorta 2a). able use stiff Amplatzer wire JR4 cross valve enter into LV. this, Tourguide (Medtronic) over amplatzer root 2b). Once root, (Thermocool Smart touch D/F curve, endocardium mapped identifying apex, base, areas abnormal voltage. cardiac then merged. Programmed stimulation RV apical inducing clinical CL 323ms 3a) bundle branch block superior axis morphology. It well tolerated pace terminated. RF (40W, max temp 43 C) targeting local ventricular activity (LAVA)1Jaïs P. Maury Khairy et al.Elimination activities: new end point substrate modification scar-related tachycardia.Circulation. 2012; 125: 2184-2196Crossref PubMed Scopus (479) Google Scholar, determine possible exit sites VT. Channel map also 3b). Post inducible, only nonclinical flutter induced cardioverted sinus. At procedure, assisted closure site 6-0 prolene close arteriotomy venotomy. recovered discharged following day. been seen one month follow-up any complaints issues arm, nor he This report knowledge underwent Touch, technology. While technique sometimes early days intracardiac shock VT2Morady F. Scheinman M. DiCarlo L. al.Catheter Ablation Ventricular Tachycardia Intracardiac Shocks: Results 33 Patients.Circulation. 1987 May; 75: 1037-1049Crossref (133) other reports exist literature describing arrhythmia upper extremity. One previous describes though radial 6Fr 4 mm tip3Kim J. Han D. Sohn C. Arrhythmias Radial Artery Patient With Prior Myocardial Infarction Peripheral Vascular Disease.Korean Circ 2012 Sep; 42: 632-637https://doi.org/10.4070/kcj.2012.42.9.632Crossref Scholar. published Europace, PVCs coronary cusp 7Fr inserted artery.4Han Bing Li Shi-jie Feng Chun-guang originating cusp.EP Europace. April 2015; 17: 670https://doi.org/10.1093/europace/euv047Crossref (0) Scholar during facilitate procedure extremely valuable. Integrated become available help guide providing anatomical information. Previously studies 5Komatsu Y. Cochet H. Jadidi A. al.Regional Wall Thinning at Multidetector Computed Tomography Correlates Arrhythmogenic Substrate Postinfarction Tachycardia.Circulation. 2013 March; 6: 342-350https://doi.org/10.1161/CIRCEP.112.000191Crossref (83) Scholar,6Cochet Komatsu Sacher al.Integration merged delayed-enhanced magnetic resonance multidetector computed tomography guidance tachycardia ablation: pilot study.J Cardiovasc Electrophysiol. Apr; 24 (Epub Dec 17. PMID: 23252727): 419-426https://doi.org/10.1111/jce.12052Crossref (87) have demonstrated cardiomyopathy that images can assess wall thinning which associated LAVA electroanatomic hence eliminate need high density voltage mapping. allows preprocedural planning (catheter choice) defining target prior starting procedure. In case, register image CartoSound (Biosense Webster), acquiring geometry vena cava, inferior sinus root. By registered image, acquire density, rather focused location diseased substrate. Within those areas, LAVA, channels between denser targeted There several important lessons learned case. first, challenging natural direction moving forward aorta. working line how electrophysiologists are catheters, similar colleagues recommend surgeons often face opposite issue accessing mesenteric arteries usually find their catheters wires ascending aorta, deflectable sheaths posterior. challenge entering system required mechanical advantage closer level entry system. Current designed carry torque deflection longer distance, however invariably motion operator’s hand will translated effectively distally. Future needed if confers additional benefit maneuvering catheter. ability control bleeding insert larger sheaths. experience inserting Fr Access took 15 min each time no manual pressure create adequate hemostasis. Lastly, complications should noted including vasospasm, thrombosis, thromboembolism distally hand, infection, poor wound healing. Our these, contrary benefitted visual supervision team, ambulatory within 1-2 hours summary, tip (inHEART). further study evaluate technique, believe offer advantages compared traditional deserving study.Key Teaching Points1.VT venous vein.2.Brachial efficient, safe method extremity heart. make navigating side.3.Integrated reduce perform especially less frequently point.