Interesting Cases: Bahman Arrhythmia Clinic : what should be reminded before ablation of RV VT

Title: what should be reminded before ablation of RV VT

A 53 year woman with history of palpitation and one documented episode of arrhythmia which was compatible with VT originating in right ventricle was admitted for electrophysiologic study and ablation.the patient had no episode of syncope and palpitation was the problem of the patient from 4 years ago.

There was no familial history of suden cardiac death ;In echocardiography report no abnormality wasevident.The resting ECG and 12 lead ECG during arrhythmia are as follows:

NSR tracing:

12 lead ECG during arrhythmia:

After isertion of diagnostic catheters the arrhythmia was induced with isupril infusion and mapping with ablation catheter revealed the best potential at inferobasal RV near tricuspid ring at which 100% matched pace map was seen.:

RF ablation with 4 mm catheter at this region terminated the arrhythmia but after cessation of each RF application the arrhythmia recurred so ablation with irrigated tip catheter permenently abolished the arrhythmia:

Successfull arrhythmia termination:

but after5 minutes the following arrhythmia appeared:

As evident the morphology of this arrhythmia is completely different from the first one.so existance of two different VT originating from RV should bring one possiblity in mind:Arrhythmogenic RV displasia.RV ventriclogram revealed RV enlargement and systolic dysfunction and the diagnosis was accertained.

The patient left the cathlab and sotalol was prescribed and ICD implantation was recommended to the patient.
This case remind the importance of exact investigation for presence of ARVD in any patient with RV-VT and the point that relying on a previously performed echocardiography would not be enough.So performing an exact echocardiography by an experted physician familiar with ARVD and if available signal average electrogram is mandatory to prevent missing the true diagnosis and also wasting much time.