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Finding the right pathway is the key to success

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1 Finding the right pathway is the key to success
Adam J. Graham, MRCP, Jonathan M. Behar, PhD, MRCP, Simon Sporton, MD, FRCP, Anthony Chow, MD, MRCP, Mehul Dhinoja, MD, MRCP, FHRS, Pier D. Lambiase, PhD, FRCP, FHRS  HeartRhythm Case Reports  Volume 5, Issue 4, Pages (April 2019) DOI: /j.hrcr Copyright © 2019 Heart Rhythm Society Terms and Conditions

2 Figure 1 A: Left lateral unipolar voltage map of right ventricle endocardium. B: Left lateral view of the endocardial activation map during ventricular tachycardia (VT). Ablation lesions are displayed on the right ventricular outflow tract septum with earliest activation in red. Note the diffuse endocardial early activation indicative of an epicardial-to-endocardial breakthrough. C: Intracardiac electrograms with surface electrocardiogram (ECG) showing broad complex tachycardia with left bundle branch block (LBBB) morphology with an inferior axis. D: A 12-lead surface ECG of VT on admission showing the same LBBB and inferior axis as during the case. RVOT = right ventricular outflow tract. HeartRhythm Case Reports 2019 5, DOI: ( /j.hrcr ) Copyright © 2019 Heart Rhythm Society Terms and Conditions

3 Figure 2 A: Epicardial bipolar voltage map created during sinus rhythm (SR), with bipolar voltage setting at 0.5 mV to 1.5 mV. Maps are displayed in right anterior oblique (RAO), anterior posterior (AP), and left anterior oblique (LAO) from left to right. B: Resting 12-lead electrocardiogram showing T-wave inversion in V1–V3. C: Late and fractionated potentials seen recorded epicardially from the decapolar catheter during SR. HeartRhythm Case Reports 2019 5, DOI: ( /j.hrcr ) Copyright © 2019 Heart Rhythm Society Terms and Conditions

4 Figure 3 A: Anteroposterior view of activation map of ventricular tachycardia (VT) superimposed onto full epicardial geometry for orientation. Early and late activation are displayed in red and blue, respectively. The area of early activation shows the diastolic activation from the isthmus of the VT circuit. B: Surface electrocardiogram leads and epicardial bipolar electrograms recorded from a decapolar catheter on the isthmus during VT. Entrance to the isthmus can be seen on poles 9–10, with diastolic electrograms seen on subsequent poles following the pathway to the exit on 1–2. RVA catheter recordings are from the right ventricular apex. C: Termination within a few seconds of ablation on the area marked with Visitags on A. HeartRhythm Case Reports 2019 5, DOI: ( /j.hrcr ) Copyright © 2019 Heart Rhythm Society Terms and Conditions

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