Options for ventricular tachycardia ablation after double valve replacement

Case report A 52-year-old man was referred for treatment of recurrent sustained monomorphic VT with variable cycle lengths (CLs) of 360 to 480 ms (125–166 bpm) causing recurrent implantable cardioverter-defibrillator (ICD) shocks despite increasing doses of amiodarone. He had rheumatic heart disease and had undergone mitral and aortic valve replacements with mechanical St. Jude prostheses as well as tricuspid valve repair 14 years previously. Two years after surgery, he had an embolic lateral wall myocardial infarction and subsequently developed recurrent episodes of heart failure, fluctuating renal dysfunction, and monomorphic VT for which an ICD was implanted. In the past year, VT episodes increased despite therapy with amiodarone at doses of up to 600 mg daily. The patient was admitted for nearly incessant slow VT with a CL of 430 ms, right bundle branch block-like configuration in lead V1, and rightward frontal plane axis, consistent with an origin in the lateral LV scar. His left ventricular ejection fraction was 20%, with LV enddiastolic diameter of 7.3 cm. Serum creatinine was 1.07 mg/dL.