Endo-Epicardial Ventricular Tachycardia Ablation With Pulsed-Field Energy in an Extravascular ICD Recipient

Background: Extravascular implantable cardioverter-defibrillator (EV-ICD) recipients may require epicardial ventricular tachycardia (VT) ablation, raising device and access considerations. First-in-human/early reports summary: A 62-year-old man with ischemic cardiomyopathy (left ventricular ejection fraction: 38%) and electrical storm despite antiarrhythmics and prior endocardial ablation underwent hybrid endo-epicardial VT ablation guided by right ventricular apex S1-S2-S3 mapping. A basal-mid inferolateral epicardial deceleration zone with local abnormal ventricular activity and a diastolic pathway were targeted. Pulsed-field (PF) applications with limited adjunct radiofrequency (RF) abolished the epicardial deceleration zone and the clinical VT; a rapid nonclinical VT remained inducible. Concomitant substernal lead repositioning was performed for noise oversensing. No complications occurred; defibrillation testing was effective, and 30-day remote monitoring showed no arrhythmic events. Discussion: A pragmatic workflow integrated computed tomography-guided epicardial planning, functional substrate mapping, PF ± RF delivery, and EV-ICD management. Novelty: This is to our knowledge the first reported combination of PF-based endo-epicardial VT ablation with concomitant substernal lead repositioning in an EV-ICD recipient. Take-home message: Hybrid PF-based VT ablation can be integrated with EV-ICD management.