In this article, the authors report on a case of left ventricular tachycardia ablation.

The AcuNav ICE catheter (Siemens Medical Solutions, Malvern, PA) is our choice for intracardiac echocardiography, because of its greater maneuverability and increased functionality over other ICE systems. We routinely use the AcuNav catheter (Siemens) for atrial fibrillation ablation, as it helps guide transseptal puncture, locate the ostia of the pulmonary veins in relation to the ablation catheter, discover potential thrombi on the transseptal sheath or mapping catheter, and allows early discovery of a pericardial effusion, should it develop.

The recent introduction of the CartoSound software (Biosense Webster, Inc., a Johnson & Johnson company, Diamond Bar, CA) has further increased functionality. CartoSound (Biosense Webster, Inc., a Johnson & Johnson company) allows construction of a real-time virtual “shell’ of the left atrium, appendage, and veins without entering the left atrium, thereby obviating the need for a preliminary left atrial CT scan or left atrial point mapping with the ablation catheter.

We report on the use of CartoSound (Biosense Webster, Inc., a Johnson & Johnson company) for a case of left ventricular tachycardia (LV VT).

Case Description

Ventricular tachycardia ablation was contemplated in a 74-year-old male patient with ischemic cardiomyopathy and a LVEF 28%, who experienced repetitive ICD shocks in response to hemodynamically unstable monomorphic VT despite amiodarone use.

During the EP study, two distinct monomorphic VTs were induced, both hemodynamically unstable. The AcuNav SoundStar catheter was introduced into the right ventricle (RV) under fluoroscopic guidance, and positioned in the long axis of the RV with the tip close to the RV apex, and reference mark pointing superiorly. The catheter shaft was then rotated counterclockwise through approximately 60 degrees, and a near-long axis view of the LV chamber was obtained. Rotating the SoundStar (Biosense Webster, Inc., a Johnson & Johnson company) counterclockwise in minute gradations, allowed construction of a real-time virtual shell of the LV. (Figure 1)

The SoundStar (Biosense Webster, Inc., a Johnson & Johnson company) was then withdrawn, until the tip lay in the mid chamber of the RV. Counterclockwise rotation allowed acquisition of the shell at the level of the papillary muscles.

Due to the ability of the SoundStar catheter (Biosense Webster, Inc., a Johnson & Johnson company) to flex by 60 degrees in all four directions, catheter introduction and shell acquisition was completed within approximately five minutes.

Using the retrograde aortic route, an 8 Fr ThermoCool catheter (Biosense Webster, Inc., a Johnson & Johnson company) was introduced into the LV. Point mapping was then performed. The presence of the shell allowed us to direct the catheter to each portion of the LV endocardium with confidence. The best orientation was a cutaway of the shell through the plane of the mitral valve, viewed from the left posterior aspect. (Figure 2)