Treatment of intramural ventricular tachycardia in cardiac sarcoidosis with transcoronary ethanol ablation

A 67-year-old man with sarcoidosis presented with recurrent ventricular tachycardia (VT) despite treatment with amiodarone. Cardiac magnetic resonance imaging demonstrated delayed enhancement of the mid-myocardium in the inferolateral wall and septum (Figure, upper panel) and cardiac positron emission tomography –computed tomography (PET-CT) showed a perfusion defect with increased uptake of 18F-fluorodeoxyglucose in the same region. Two inducible VTs were both mapped to the cardiac crux along the inferior interventricular septum (RBBB, superior axis and LBBB, superior axis, respectively). Prior attempts at radiofrequency (RF) catheter ablation, including epicardial and bipolar transmural RF ablation, as well as haemodynamic support with extracorporeal membrane oxygenation, were not successful. Because of VT storm, the patient underwent transcoronary ethanol ablation, which targeted a right posterol ateral (RPL) branch which supplied this region. Balloon occlusion of the distal RPL during VT reproducibly terminated the tachycardia within 30–50 s (Figure, lower panel), and ethanol ablation prevented inducibility. During 2 years of follow-up, he required one other endocardial ablation to tr eat VT from a lateral LV location, and then had only one recurrence. We propose that alcohol ablation should be considered in patients with sarcoidosis who have intramural VTs that fail endocardial and epicardial ablation and are refractory to conventional therapy.
Source: Europace - Category: Cardiology Source Type: research