Successful Substrate-Guided Ablation of Ventricular Tachycardia Storm in Acute Heart Failure Without Mechanical Circulatory Support (JACC Case Reports December 2025)-Article: Successful Substrate-Guided Ablation of Ventricular Tachycardia Storm in Acute Heart Failure Without Mechanical Circulatory Support

Article: Successful Substrate-Guided Ablation of Ventricular Tachycardia Storm in Acute Heart Failure Without Mechanical Circulatory Support

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This JACC Case Reports article describes a 62-year-old man with advanced ischemic cardiomyopathy (LVEF 25%–30%, NYHA class III) who developed recurrent monomorphic ventricular tachycardia (VT) storm after a recent myocardial infarction with failed revascularization of a dominant proximal right coronary artery occlusion. Despite treatment with amiodarone and lidocaine, he continued to have sustained VT requiring repeated cardioversions and showed signs of worsening acute heart failure with multiorgan dysfunction (acute kidney injury, mild liver enzyme elevation, markedly elevated NT-proBNP). His PAINESD score was 23, indicating high risk for hemodynamic collapse during VT ablation. Mechanical circulatory support (MCS) and advanced imaging were not available, creating a major challenge in a high-risk patient.<br /><br />Because VT storm persisted and clinical deterioration continued, the team proceeded with urgent catheter ablation using a strategy designed to minimize time spent mapping during unstable VT. Under monitored anesthesia care (propofol and midazolam) with individualized hemodynamic support (norepinephrine and low-dose dobutamine), VT was managed intraoperatively with lidocaine, pacing maneuvers, and external cardioversion as needed. Electroanatomic mapping identified a large scar/low-voltage region in the basal posterior septal left ventricle. Functional substrate mapping techniques—voltage mapping, late potentials, local abnormal ventricular activity (LAVA), isochronal late activation mapping (ILAM) to identify deceleration zones, and decrement-evoked potential (DeEP) mapping—localized a critical VT isthmus in the basal posteroseptal LV.<br /><br />Radiofrequency ablation at mid-diastolic signals slowed and terminated VT within 30 seconds, followed by additional substrate modification targeting deceleration zones and abnormal potentials. Post-ablation stimulation could not reinduce VT. The patient completed the 3-hour procedure without escalation of support, received an implantable cardioverter-defibrillator two days later, and was discharged off antiarrhythmic drugs. At two weeks he remained stable without VT recurrence. The report concludes that functional substrate-guided mapping plus tailored anesthesia/hemodynamic management can enable safe, effective VT storm ablation even in resource-limited settings, though MCS may still be necessary for patients in severe shock or with incessant VT.

Keywords

ventricular tachycardia storm

ischemic cardiomyopathy

catheter ablation

functional substrate mapping

isochronal late activation mapping (ILAM)

decrement-evoked potential (DeEP) mapping

local abnormal ventricular activity (LAVA)

late potentials

PAINESD score

resource-limited setting