Epicardial Ventricular Tachycardia Originating From the Left Ventricular Outflow Tract: Challenges and Management.

BACKGROUND

Ventricular tachycardia (VT) storm from the left ventricular outflow tract epicardium is challenging, especially after coronary artery bypass grafting and mechanical aortic valve replacement.

CASE SUMMARY: A 68-year-old man with history of coronary artery bypass grafting, mechanical aortic valve replacement, hypertension, diabetes, and untreated chronic obstructive pulmonary disease presented with recurrent chest tightness, palpitations, syncope, and symptomatic wide QRS complex VT. He developed VT storm (>100 implantable cardioverter-defibrillator shocks/d). Trans-coronary sinus-great cardiac vein (CS-GCV) ablation (guided by three-dimensional mapping) succeeded; no postprocedural VT/premature ventricular contractions, with sustained efficacy on follow-up.

DISCUSSION: This case demonstrates that CS-GCV ablation manages epicardial VT storm despite anatomical challenges. Preprocedural imaging and intraoperative navigation are key; PTCA wire unipolar mapping optimizes targeting, reducing complications versus retrograde aortic access in post-valve surgery patients.

TAKE-HOME MESSAGES: Epicardial VT storm can be managed via CS-GCV ablation despite anatomical challenges. Preprocedural imaging/intraoperative navigation ensure success; PTCA wire mapping optimizes targeting, and intracardiac echocardiography ensures safety. It is safer than retrograde aortic access for post-valve surgery patients.