Bail-out alcohol septal ablation in the management of obstructive hypertrophic cardiomyopathy and refractory electrical storm. How would I approach it?

Abstract

HOW WOULD I APPROACH IT? Authors describe the case of a 51-year old patient with obstructive hypertrophic cardiomyopathy with unusual clinical presentation and progression. The patient had repeated episodes of sustained monomorphic ventricular tachycardia (VT) that required defibrillator implantation in secondary prevention and pharmacological treatment with amiodarone and beta-blockers. Afterwards, the patient experienced an arrhythmic storm with appropriate multiple discharges despite the antiarrhythmic medication. The stellate ganglion block was indicated. Modulating the sympathetic nervous system can be effective to suppress the arrhythmic storm, but I think of it as the last option. The first therapeutic strategy here would have been the electrophysiological study and the substrate-based ablation of VT. The ablation of recurring VT has a high rate of success with obstructive hypertrophic cardiomyopathies with apical aneurysm and a clear anatomical substrate. However, when this is not the case and there are several fibrotic areas like this patient’s cardiovascular magnetic resonance (CMR) imaging showed, the utility of ablation is limited. According to the electrocardiogram and late gadolinium enhancement CMR imaging, the origin of VT could be septal. The authors describe that the intracardiac mapping showed septal macroreentrant whose ablation failed. The endocardium catheter ablation is expected to fail in cases like this...