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Radiofrequency Wire Facilitated Interventricular Septal Access for Catheter Ablation of Ventricular Tachycardia in a Patient With Aortic and Mitral Mechanical Valves.

A 53-year-old woman, with history of rheumatic heart disease, double Starr-Edwards caged-ball mechanical valves in the mitral and aortic position (Figure [A]), and embolic infarct in the left anterior descending coronary territory, presented with recurrent ventricular tachycardia (VT) refractory to escalating doses of antiarrhythmic drugs and leading to multiple implantable cardioverter-defibrillator interventions. Preprocedural imaging with transthoracic echocardiogram and contrast-enhanced computed tomography demonstrated a large left ventricular (LV) apical aneurysm with dense calcifications (Figure [B] and [C]). A transapical surgical access was deemed not optimal given the apical location of the substrate, the presence of calcifications, and the requirement for oral anticoagulant discontinuation with the history of thromboembolism. A percutaneous transinterventricular septum puncture was planned to access the LV. The procedure was performed on full systemic anticoagulation with uninterrupted warfarin (INR=2.8) and intravenous heparin (target activated clotting time 350 seconds). The right internal jugular vein was accessed, and a deflectable sheath (Agilis NxT; St. Jude Medical) was advanced to the basal right ventricular (RV) septum as visualized by intracardiac echocardiography (ICE) (Figure [D] and [E]). After confirming a safe distance from the coronary septal perforator branches with both left and right coronary angiography, the interventricular septum was crossed with a 0.035-inch endovascular radiofrequency wire (PowerWire; Baylis Medical, Inc) applying radiofrequency energy at the tip of the wire (10 W for 4 seconds) and guided by direct imaging with ICE (Figure [F]; Movie SI in the Data Supplement). Once the dilator was advanced within the left ventricle over the radiofrequency wire, in order to facilitate the advancement of the sheath over the dilator, the …