Combined Right Ventricular Outflow Tract Epicardial and Endocardial Late Potential Ablation for Treatment of Brugada Storm: A Case Report and Review of the Literature

Abstract

A 34-year-old man with Brugada syndrome (BrS) presented with electrical storm, manifested as multiple appropriate shocks from his implantable cardioverter-defibrillator over a period of 7 hours. He had not tolerated prior treatment with quinidine, and had self-discontinued cilostazol citing persistent palpitations. After stabilization with intravenous isoproterenol, an electrophysiology study was performed but no spontaneous or induced ventricular ectopic beats were identified. A three-dimensional (3D) endocardial electro-anatomic map of the right ventricular outflow tract (RVOT), pulmonic valve, and pulmonary artery, as well as a 3D epicardial map of the RVOT, were created. Low voltage, complex, fractionated electrograms and late potentials were targeted for irrigated radiofrequency ablation both endocardially and epicardially. Post-procedure, he was maintained on cilostazol (referring clinician preference), and has had no further ventricular tachyarrhythmia episodes over the past forty-one months. We propose that this novel ablation strategy may be useful for acute management of selected patients with BrS.

Isolated diastolic potentials as predictors of success in ablation of right ventricular outflow tract idiopathic premature ventricular contractions

“…We did not find, in the literature, any other reports of diastolic potentials identical to ours, except for a clinical case published by Saha et al [21], in 2016. It describes a patient with Brugada syndrome and arrhythmic storm that underwent catheter ablation.…”

Catheter ablation for electrical storm in Brugada syndrome: Results of substrate based ablation

“…Many non-invasive and invasive studies have shown that EP abnormalities responsible for cardiac arrhythmias in BrS are located in RVOT and anterior right ventricular area 4, 10, 11, 12, 13, 14. Electrophysiological abnormalities in the form of late potentials, fractionated potentials, split potentials and low voltage areas were noticed in our patients in endocardial as well as epicardial surface of RVOT/right ventricular area as reported by some authors 10, 11, 13, 15. Substrate modification, either endocardial or epicardial has shown to prevent recurrent VT/VF and ICD shocks in these patients 10, 11, 13, 15…”

“…Intravenous infusion of isoproterenol may be useful in BrS with ES. There are few reports of successful RF ablation by to prevent recurrence of VT/VF 4, 10, 11, 12, 13, 15…”

“…All patients are free of ES, however one patient had one VF shock 24 months post ablation. Saha et al 15 reported a case of BrS with electrical storm with both endo and epicardial substrate. They performed combined ablation of both the surfaces of RVOT and reported long term freedom from VT/VF.…”

Early Response after Catheter Ablation of the Epicardial Substrate in a Patient with Brugada Syndrome Can Be Predicted by High Precordial Leads

“…Delayed depolarization over the anterior aspect of the RVOT epicardium was suggested as the underlying electrophysiological mechanism in Brugada syndrome, and catheter ablation over this abnormal area resulted in normalization of the Brugada ECG pattern and prevented VF episodes [ 3 ]. A combined epicardial and endocardial ablation strategy for Brugada syndrome targeting low-voltage, fractionated late potentials in the RVOT was reported recently [ 4 ]. We performed endocardial substrate mapping before attempting the epicardial approach; however, there were no abnormal electrocardiograms to target.…”