Successful catheter ablation targeting triggering premature ventricular contractions and continuous propagating activity: Suppression of ventricular fibrillation storms in ischemic cardiomyopathy

Ventricular fibrillation (VF) storm is a life-threatening condition that is particularly challenging to manage when resistant to conventional therapies such as antiarrhythmic drugs, deep sedation, overdrive pacing, and hemodynamic support. We report a case of a 55-year-old male with ischemic heart disease and recurrent VF storm unresponsive to initial treatments, requiring percutaneous cardiopulmonary support to stabilize hemodynamics. A left ventricular inferoseptal Purkinje-related premature ventricular contraction (PVC) was identified as the VF trigger, with continuous propagating activity involving Purkinje and myocardial substrates as the driver. Targeted radiofrequency catheter ablation (RFCA) at the earliest activation site of the triggering PVC and continuous propagating activity effectively suppressed VF and maintained stable sinus rhythm. The patient was successfully weaned off support devices and was discharged with an implantable cardioverter-defibrillator. This case highlights the importance of accurately localizing triggers and drivers in refractory VF management and suggests the efficacy of RFCA in managing VF storm associated with structural heart disease.

Learning objective

1. The origin and exit of the Purkinje-related triggering premature ventricular contraction (PVC) differed. 2. During initiation of ventricular fibrillation (VF), the Purkinje and myocardial potentials fused, exhibiting continuous propagating activity in the limited area surrounding the origin and exit of the triggering PVC. 3. Radiofrequency catheter ablation targeting both the triggering PVC and continuous propagating activity demonstrated notable efficacy in the suppression of the VF storms.