Thread by @alanhanley2

#EPeeps Exciting approach to challenging PVC @MGHHeartHealth. Referred for epicardial ablation.
1/n

With patient's permission.

The PVC that can dodge V1 - 3 has a survival advantage

Aha! There it is. Looks like ATV3 @DrRoderickTung

Mapping of multiple chambers (LVOT/RVOT/Aorta/CS + branches) -> simultaneous earliest EGMs ~ 20-25ms pre-QRS LV endo and CS branch. Earliest components look kind of farfield.

Sweet propagation map by @svTri24

Cue attempted ablation from inside the LV. Power uptitrated to 50W, half normal irrigant, dispersive patch on the anterior chest, 150 second lesions... very transient suppression or no effect.

Cue attempted ablation from the CS (actually a small branch the EP star was in). Pop after 15 seconds. Transient suppression. Not trying that again.

2F EP star in green, Map-It in white. Check out the reversal of EGM components in EPS 1,2 and 3,4 (and Map-It 5,6) from normal to ectopic.

Decided to ablate bipolar from best LV endo site to EP star 2-3 in a small CS branch. Need to make sure there are no septal perforators there, we are very basal. Pro tip from EP fellow @GCFernandesMD: use the map to determine the best angio view. LAO cranial here:

Coast is clear. 15W

Yes, 15W. Good impedance drop, instant therapeutic effect so no titration. Bipolar is a big gun: need to aim carefully. Happy Thanksgiving everyone!

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