Colocalized radiofrequency and pulsed field ablation of incessant ventricular tachycardia with suspected intramural circuit in ischaemic cardiomyopathy using a 3.5 mm single-tip catheter under eCPR: a case report

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Background: Incessant ventricular tachycardia (VT) in advanced ischaemic cardiomyopathy is a life-threatening condition, particularly when maintained by deep intramyocardial scar channels that can be difficult to eliminate with conventional radiofrequency (RF) ablation. Pulsed-field ablation (PFA) is a non-thermal, myocardium-selective modality with the potential to target arrhythmogenic tissue while minimizing collateral injury. Case summary: We report a case of incessant VT in a 60-year-old man with severe ischaemic cardiomyopathy in whom acute VT termination and final non-inducibility were achieved using a sequential dual-energy strategy combining RF and PFA delivered with a 3.5 mm open-irrigated catheter capable of both modalities [Dual Energy THERMOCOOL SMARTTOUCH™ (DE-STSF), Johnson & Johnson MedTech]. The procedure was performed under extracorporeal cardiopulmonary resuscitation (eCPR) via veno-arterial extracorporeal membrane oxygenation (VA-ECMO) during electrical storm. Despite VT termination and arrhythmia control, the patient died on Day 5 from refractory shock with progressive multiorgan failure. Discussion: This case supports the feasibility of colocalized sequential RF-PFA ('energy stacking') as an adjunct strategy for suspected intramural post-infarction VT substrate in selected high-risk patients. Supported by VA-ECMO, this dual-energy strategy achieved acute VT non-inducibility and arrhythmia control, despite an unfavourable overall clinical outcome. Further systematic evaluation is warranted to define the incremental role of dual-energy lesion delivery in ventricular substrates.

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