Hybrid surgical epicardial cryoablation for ventricular tachycardia in the electrophysiology laboratory: a case report.

Background: Scar-related ventricular tachycardia (VT) is a challenging medical condition, with catheter ablation providing a valuable treatment option. Whilst most VTs can be ablated endocardially, epicardial ablation is often required in patients with non-ischaemic cardiomyopathy. The percutaneous subxiphoid technique has become instrumental for epicardial access. However, it is not feasible in up to 28% of cases for multiple reasons. Case summary: A 47-year-old patient was managed at our centre for VT storm and recurrent implantable cardioverter defibrillator shocks for monomorphic VT despite maximum drug therapy. No scar was noted during endocardial mapping, with confirmation of the localized epicardial scar on cardiac magnetic resonance imaging (CMR). Following failed percutaneous epicardial access, a successful hybrid surgical epicardial VT cryoablation via median sternotomy was performed in the electrophysiology (EP) laboratory utilizing data from CMR, prior endocardial ablation, and conventional EP mapping. The patient has remained arrhythmia-free for 30 months post-ablation without antiarrhythmic therapy. Discussion: This case describes a practical multidisciplinary approach to managing a challenging clinical problem. Whilst the described technique is not entirely novel, this is the first case report that describes the practicalities and demonstrates the safety and feasibility of hybrid epicardial cryoablation via median sternotomy performed in the cardiac EP laboratory for the sole treatment of VT.