Our patient is unique in that he has ischemic cardiomyopathy with a focal origin for his VF. Polymorphic VT/VF and electrical storm occurring in this setting are often attributed to acute ischemia or electrolyte abnormalities, and this was not noted in our patient. Although focal origin of VT and successful catheter ablation of VT have been reported for more than 15 years, focal ablation of VF has been reported for the first time in 2002 in patients with idiopathic VF. Our case preceded these reports and is the first one describing transcatheter ablation for VF in ischemic cardiomyopathy.

Transcatheter ablation has been tried with success in patients with VT in the absence of underlying structural heart disease and those with idiopathic right ventricular outflow tract VT or idiopathic left-sided VT and bundle-branch re-entrant VT. Treatment of polymorphic VT/VF in ischemic cardiomyopathy usually requires revascularization or intravenous amiodarone. Our patient had unchanged coronary circulation on coronary angiogram and normal cardiac enzymes and electrolytes during his hospitalization. The use of multiple antiarrhythmic agents, including intravenous amiodarone, was not effective. The results we achieved lend credence to the fact that patients presenting with apparent disorganized ventricular arrhythmia—even in ischemic cardiomyopathy—may indeed have a focal or localized region of origin. A single scroll wave can give rise to extremely irregular electrocardiogram characteristic of fibrillation. silagra uk

Haissaguerre et al. in 2002 reported 27 patients with recurrent primary idiopathic VF who had ablation therapy in six centers. Triggers were localized by mapping the earliest electrical activity and ablated by radiofre-quency delivery. Twenty-four of them had no recurrence of VF after the ablation. Similar patients as described byHaissaguerre et al. and other authors should have a close scrutiny of the initiating focus of their VF or polymorphic VT.

Catheter ablation for VF was described in patients with structurally normal hearts and in patients with nonischemic cardiomyopathy. We describe a patient with ischemic cardiomyopathy who had patent grafts with no evidence of acute ischemia at presentation. His chest pain was felt to be due to ventricular arrhythmia. Radiofrequency application delivered in a criss-cross manner to a one-square-centimeter area of the anterolateral apical free wall of the left ventricle was successful in terminating this arrhythmia. Following radiofrequency ablation and observation for an hour on the table, we then discontinued all his antiarrhythmic drugs. After 48 hours of freedom from polymorphic VT/VF and electrical storm, he received a defibrillator for subsequent prevention of sudden cardiac death. He has been followed for greater than two years and has not had a recurrence of sustained arrhythmia or received therapy from his defibrillator. The incessant nature of the presenting arrhythmia precluded him initially even from ICD treatment. Ability to attain control of the arrhythmia with catheter ablation made it possible for him to receive an ICD. prescription drugs online pharmacy

Disorganized atrial and ventricular arrhythmias are now being recognized to generally have a focal mechanism of initiation. Current ability to treat and cure patients with atrial fibrillation by directing catheter ablation to focal sites of origin in the pulmonary veins indicates and supports the concept that the mechanism of initiation of atrial fibrillation is different from the ability for fibrillatory conduction. In conclusion, focal initiation of polymorphic VT/VF has to be considered in certain instances, even in patients with ischemic cardiomyopathy. The ability to intervene as electro-physiologists in similar circumstances may help patients much like the one we treated.