Successful catheter ablation of electrical storm after myocardial infarction

Background - We report on 4 patients ( aged 57 to 77 years; 3 men) who developed drug-refractory, repetitive ventricular tachyarrhythmias after acute myocardial infarction (MI). All episodes of ventricular arrhythmias were triggered by monomorphic ventricular premature beats (VPBs) with a right bundle-branch block morphology (RBBB). Methods and Results - Left ventricular (LV) mapping was performed to attempt radiofrequency (RF) ablation of the triggering VPBs. Activation mapping of the clinical VPBs demonstrated the earliest activation in the anteromedial LV in 1 patient and in the inferomedial LV in 2 patients. Short, high-frequency, low-amplitude potentials were recorded that preceded the onset of each extrasystole by a maximum of 126 to 160 ms. At the same site, a Purkinje potential was documented that preceded the onset of the QRS complex by 23 to 26 ms during sinus rhythm. In 1 patient, only pace mapping was attempted to identify areas of interest in the LV. Six to 30 RF applications abolished all local Purkinje potentials at the site of earliest activation and/or perfect pace mapping and suppressed VPBs in all patients. No episode of ventricular tachycardia or fibrillation has recurred for 33, 14, 6, and 5 months in patients 1, 2, 3, and 4, respectively. Conclusions - Incessant ventricular tachyarrhythmias after MI may be triggered by VPBs. RF ablation of the triggering VPBs is feasible and can prevent drug-resistant electrical storm, even after acute MI. Catheter ablation of the triggering VPBs may be used as a bailout therapy in these patients.