Po-04-061 a rare case of focal left ventricular outflow tract ventricular tachycardia late after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is commonly used to treat severe aortic stenosis (AS). To date there is only one reported case of post-TAVR, new onset, left ventricular outflow tract (LVOT) ventricular tachycardia (VT) which was ablated above the TAVR valve. We report a case of late presenting symptomatic LVOT VT, which was successfully ablated via a trans-septal approach, without fluoroscopy, using intracardiac echocardiography (ICE) and electroanatomic mapping (EAM), thereby, avoiding catheter manipulation in the aorta above the valve. N/A A 68-year-old man underwent TAVR for severe AS with Sapien 3 valve (Edwards Lifescience). Nine months later, the patient developed worsening dyspnea. Echocardiogram showed well seated TAVR valve, and exercise nuclear stress revealed no ischemia. During the stress test, he had slow monomorphic VT at rest, during exercise, and recovery (100-120 bpm). A 24-hour Holter monitor revealed a ventricular arrhythmia burden of 55% with rates between 85 and 112 bpm. The 12-lead ECG of VT had an initial positive deflection in lead I, QS in V1 and V2, and an initial R wave in V3 taller than the sinus QRS, suggesting a septal right ventricular outflow tract (RVOT) vs. LVOT origin. There was no improvement with beta-blocker therapy. An electrophysiology study was performed using ICE and CARTO (Biosense Webster, Diamond Bar, CA). Activation mapping in the septal RVOT revealed a 20ms presystolic electrogram (far field) and an 80% pace map, despite the unipolar signal with QS complex. Radiofrequency ablation performed at this site only mildly suppressed the arrhythmia. The decision was made to map from the LVOT via transseptal access using EAM and real-time markers from Cartosound real time images to accurately visualize the ablation catheter below the TAVR. Earliest activation was beneath the left coronary cusp directly across the RVOT lesions with a sharp 22ms pre-systolic electrogram, unipolar QS, and 90% pace map match. Ablation performed here successfully eliminated the VT even after isoproterenol infusion and programmed stimulation. The patient’s symptoms have resolved, and he remains arrhythmia free. LVOT VA’s may rarely occur post TAVR, although a direct cause cannot be ascertained. This is the first report of successfully ablating the arrhythmia in a TAVR patient using a transeptal, subvalvular approach without fluoroscopy, and avoiding any risks associated with the aortic approach.