The Storm Before the Calm: Ablation of Premature Ventricular Complex Trigger for Incessant Ventricular Fibrillation

Abstract

Ventricular tachycardia storm is associated with high mortality rates and is often refractory to treatment. Historically, few options for treatment have existed in cases when antiarrhythmic drugs fail. We report the case of a patient with incessant ventricular fibrillation (VF) in the postinfarction period that was triggered by premature ventricular contractions (PVCs) that persisted despite normal electrolytes, exclusion of ongoing ischemia, infusions of antiarrhythmic drugs, general anesthesia, full circulatory support with extracorporeal membranous oxygenation, and cardiac sympathetic denervation. Given that the VF appeared to be triggered consistently by a unifocal, short-coupled PVC (consistent with Purkinje fiber–mediated VF), we performed catheter ablation, after which point, the patient experienced no further PVCs or ventricular arrhythmia. This case serves as a reminder of three key teaching points. First, not all VF is created equal, with some cases being chiefly the result of a vulnerable substrate and others being best accounted for by frequent triggers. Second, examining the available electrocardiographic data and appropriately interpreting them can guide the selection of therapies up to and including catheter ablation for treatment-refractory VF. Third, full circulatory support greatly facilitates successful electroanatomic mapping and catheter ablation of unstable ventricular arrhythmias.

The Initial Part of Polymorphic Ventricular Tachycardia as a Clue for the Sustainability of Tachycardia and Ablation Success: A Varying Degree of Purkinje–Myocardial Complicity?

“…Catheter ablation targeting the PP responsible for triggering VF is possible and efficacious in several conditions, including idiopathic VF (a short-coupled variant of torsade de pointes), ischemic VF, and chronic myocarditis. 1 , 8 , 9 , 22 , 32 The optimal time for ablation is often at the time of an ES. The most important issue before the ablation session is the recording of a 12-lead ECG of the triggering event, which can prove invaluable in regionalizing the origin of the triggering PVC/PHC or runs for more detailed mapping.…”