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Ventricular tachycardia is not an uncommon complication of ischemic heart disease, in particular those with poor heart function. This is usually well controlled with antiarrhythmic drugs and AICD. In experienced center, catheter ablation provides additional option with high success rate.
In our case, the patient is status post CABG with moderately poor LVEF and further complicated by VT. He presented to us with refractory VT which failed to respond to standard medical therapy. While being worked up for catheter ablation, LV apical thrombus was detected, hence contra-indicated the procedure due to high risk of embolization.
Staged surgical removal of LV clot followed by staged catheter ablation was then considered. In view of his patent bypass grafts, redo-sternotomy was deemed higher risk than left thoracotomy approach. Through the latter approach, dissection of pericardial adhesion and cardiac manipulation were not required. Hence, further reducing the risk of cardiac embolus and injury to the patent grafts. Visibility of surgical field was excellent and guided by epicardial echocardiography probe, the LV thrombus can be localized precisely to allow accurate ventriculotomy. The subsequent removal of clot and DOR procedure were straightforward. In addition, radiofrequency ablation was performed at the border of healthy and scarred myocardium to reduce the risk of post-operative VT. Post surgery, the patient made a remarkably well recovery with minimal pain from his thoracotomy wound. The benefit of the intra-operative RF ablation was evidenced by absence of clinical VT. His inducible VT by PES was subsequently easily ablated.
Through this unique case, we concluded that the above hybrid approach is a reasonable treatment option to consider. Left thoracotomy is safe and probably a better approach than redo-sternotomy.