Lamin Cardiomyopathy (LC) is associated with refractory ventricular arrhythmias. Catheter ablation success rate is low due to presence of multiple circuits and intramural substrate. We present a LC case presented with electrical storm. During catheter ablation, arrhythmia was easily inducible but activation mapping, including full epicardial and endocardial mapping, failed to demonstrate the full tachycardia cycle length (70% only) suggesting intramural activation. Critical isthmus was not identified even with successful concealed entrainment on both Endo/epicardial surfaces. This case shows that even combined endocardial and epicardial catheter approach can be ineffective in identifying the full arrhythmogenic substrate in LC.

Background: Ventricular tachycardia (VT) remains a leading cause of morbidity and sudden death. Improvements in catheter ablation have significantly advanced this option as a treatment method for refractory VT. Despite advances, use and impact of inotrope and vasodepressor medicines as part of intraprodcedural management during VT ablation have been understudied. Methods: We conducted a exploratory, retrospective analysis of consecutive patients undergoing VT ablation. Patient, intra and peri-procedural data, focusing on pressor use and hemodynamics through ablation, and procedural endpoint data were collected. Results: From 2014-2017, 149 patients underwent VT ablation of which 67% exhibited cardiomyopathy (53% ischemic). Most procedures (71%) were conducted under general anesthesia. In those with cardiomyopathy, steady-state use of dobutamine and dopamine was more common though substantial use of phenylephrine was noted. In adjusted analyses, (1) dobutamine was associated with increased procedure time (402.5±18.8 vs 347.2±14.0 min, p = 0.03), (2) dopamine was associated with increased number of distinct VTs (2.8 vs. 2.2, p<0.001) while both dopamine and dobutamined resulted in increased intra-procedural cardioversions (1.3 vs. 0.6, p<0.001 and 1.34 vs. 0.66, p=0.001, respectively) and (3) dobutamine dose exhibited a linear correlation with post-ablation length of stay. Conclusions: In this exploratory work, we sought to understand effects of hemodynamic drug use on short-term, procedural outcomes of VT ablation. Salient findings include: (1) arrhythmogenic nature of inotropes resulting in an increase in intraprocedural cardioversions, (2) greater propensity for induction of non-clinical VTs with use of intraprocedural dopamine and (3) substantial use of phenylephrine in those with underlying cardiomyopathy.