Received: 10 January 2018 DOI: 10.1002/ccr3.1577
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Revised: 9 April 2018
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Accepted: 15 April 2018
CASE REPORT
Pathology after a combination of sequential and simultaneous unipolar radiofrequency ablation of ventricular tachycardia in a postmortem heart with cardiac sarcoidosis Koji Miyamoto1 Kengo Kusano1
| Taka-aki Matsuyama2 | Takashi Noda1 | Hatsue Ishibashi-Ueda2 |
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Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan 2
Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan Correspondence Koji Miyamoto, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan. Email:
[email protected]
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Key Clinical Message This report shows a postmortem examination of a heart performed in a patient with cardiac sarcoidosis undergoing a sequential and simultaneous unipolar radiofrequency ablation. A combination of a sequential and simultaneous unipolar radiofrequency ablation might be useful for creating transmural ablation lesions on the interventricular septum in patients with cardiac sarcoidosis. KEYWORDS ablation, nonischemic cardiomyopathy, pathology, ventricular tachycardia
| IN T RO DU C T ION
A postmortem examination of the heart was performed in a patient with cardiac sarcoidosis undergoing simultaneous unipolar radiofrequency (SURF) ablation on the interventricular septum. The pathologic findings showed that a transmural lesion had been created with the SURF ablation. Controlling ventricular tachycardias (VTs) is important in patients with nonischemic cardiomyopathy (NICM). A combined approach to the VT management using antiarrhythmic drugs and radiofrequency catheter ablation (RFA) is often required to control such VTs.1-3 Because the VTs in patients with NICM occur based on a complex underlying substrate in the endocardium, epicardium, and/or intramural region, transmural lesion creation is necessary to manage these VTs. Saline-irrigated catheters create deeper and larger ablation lesions than nonirrigated catheters and improve the outcome of RFA.4 However, despite the use of open-irrigated ablation catheters, creating transmural ablation lesions is difficult, and the management of VTs in patients with NICM is still challenging.5-9
To overcome the limited lesion creation with RFA, some techniques to improve it have been developed, such as simultaneous unipolar radiofrequency (SURF) ablation, bipolar ablation, needle ablation, and transcoronary ethanol ablation.10-17 In this case report, we evaluated the pathologic features after a SURF ablation of a VT in a postmortem heart with cardiac sarcoidosis.
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| CASE
The patient was a 65-year-old man histopathlogically diagnosed with cardiac sarcoidosis at the age of 35 years. The 12-lead electrocardiogram exhibited an intraventricular conduction disturbance and left superior axis. The left ventricle (LV) exhibited a progressive dilation with a contractile dysfunction (severe hypokinesis on the inferior and inferior and septum). He was implanted with a cardiac resynchronization therapy device with defibrillator capability. In spite of the administration of amiodarone 100 mg, sotalol 160 mg, carvedilol 7.5 mg, mexiletine 400 mg, enalapril 2.5 mg, and
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. Clin Case Rep. 2018;1–6.
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wileyonlinelibrary.com/journal/ccr3 1
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spironolactone 25 mg, the patient was admitted to our hospital due to repetitive drug-resistant VT episodes and decompensated heart failure. The LV exhibited dilation and contractile dysfunction with an LV ejection fraction of 18%. In addition to the amiodarone, sotalol, carvedilol, mexiletine, enalapril, and spironolactone, intensive treatment of a VT storm and decompensated heart failure was performed with lidocaine 40-100 mg/h and furosemide; however, the VTs still could not be controlled.
MIYAMOTO et al.
Paced rhythm
VT
2.1 | Electrophysiological examination and ablation procedure The clinical VT on the 12-lead electrocardiogram exhibited a right bundle branch block pattern and left superior axis (Figure 1). The VT cycle length was 380 millisecond, with a widened QRS duration of 184 millisecond. RFA was performed to manage the VT storm. Steerable catheters were inserted from the right femoral vein and placed in the right atrium and ventricle of interest. The LV endocardium was accessed using the trans-septal approach. Electroanatomical mapping was performed with EnSite (Abbott, Chicago, IL). A 3.5-mm open-irrigated ablation catheter (Therapy™ Cool Path™ Duo: Abbott) was used for the ablation and mapping. Bipolar voltage maps of the endocardium of the LV and right ventricle (RV) were constructed at baseline (pacing rhythm). Low voltage zones, defined as
