Combined Endocardial Pulsed Field: Radiofrequency Ablation of a 3-Dimensional Ventricular Tachycardia With MidMyocardial Isthmus.

backgroundEpicardial access for ventricular tachycardia (VT) ablation may be limited in patients with previous cardiac surgery. Substrate depth is a key determinant of ablation success, and deep intramural circuits may not be adequately targeted with conventional endocardial radiofrequency (RF) ablation alone. CASE SUMMARY: Recurrent VT in a patient with previous cardiac bypass surgery and failed endocardial RF ablation. Mapping demonstrated a midmyocardial isthmus, successfully targeted with VT interruption by using focal combined endocardial pulsed field (PF) and RF ablation. DISCUSSION: Emerging in vivo evidence suggests that successive PF applications, as well as combined RF-PF ablation, can enhance lesion depth. This case demonstrates immediate VT termination and subsequent noninducibility with successive endocardial PF-RF lesions directly apposed to the far-field midmyocardial/epicardial isthmus, demonstrating the critical depth achieved in real time. TAKE-HOME MESSAGE: Hybrid RF-PF energy delivery may expand the therapeutic options for complex multiplanar VT circuits when epicardial access is not feasible.