CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 2, March/April 2014
AFRICA
e1
Case Report
Unusual perforation of the left ventricle during radio-
frequency catheter ablation for ventricular tachycardia
Jin-Tao Wu, Jian-Zeng Dong
Abstract
Cardiac perforation during catheter-based radiofrequency
ablation procedures is relatively uncommon but potentially
fatal if tamponade ensues. This complication should be
promptly recognised. We present a case of incomplete perfo-
ration of the left ventricle with transient ST-segment eleva-
tion in leads V
1
to V
3
during catheter ablation of ventricular
tachycardia. Complete perforation was avoided because of
rapid diagnosis by the detection of subtle changes in electrode
potentials and by performing angiography via an externally
irrigated ablation catheter lumen.
Keywords:
cardiac perforation, tamponade, left ventricle, cath-
eter ablation, ventricular tachycardia
Submitted 27/3/13, accepted 9/12/13
Cardiovasc J Afr
2014;
25
: e1–e4
DOI: 10.5830/CVJA-2013-087
Catheter-based radiofrequency ablation procedures are
currently being performed in invasive laboratories with
increasing frequency. An increased incidence of catheter-related
complications may be encountered.
1
One potentially fatal
complication is acute haemorrhagic tamponade secondary to
inadvertent cardiac perforation. Cardiac perforation should be
promptly recognised to avoid subsequent tamponade.
We present a case of incomplete perforation of the left
ventricle with transient ST-segment elevation in leads V
1
to
V
3
during catheter ablation of ventricular tachycardia (VT).
Complete perforation was avoided because of rapid diagnosis
by the detection of subtle changes in electrode potentials and
by performing angiography via an externally irrigated ablation
catheter lumen. This case study shows that physicians should
be aware of the need to promptly recognise cardiac perforation.
Case report
A 60-year-old woman with a history of drug-refractory
paroxysmal VT underwent two unsuccessful catheter ablations
at two different institutions nine years and one year previously.
She was then referred to our centre for VT ablation.
Her physical examination and chest X-ray were normal.
Transthoracic echocardiography showed normal anatomical
structure of the heart and left ventricular ejection fraction (60%).
Arrhythmogenic right ventricular cardiomyopathy (ARVC)
was excluded by myocardial magnetic resonance imaging.
Percutaneous coronary artery angiography was performed before
the ablation procedure and coronary artery disease was excluded.
An electrophysiological study was then performed. Left
subclavian vein access was obtained and a steerable 10-pole
catheter (Inquiry™, IBI, St. Jude Medical, St Paul, MN, USA)
was positioned in the coronary sinus. One quadripolar catheter
(Cordis, Biosense Webster, Diamond Bar, CA, USA) was
positioned in the right ventricle via left femoral vein access and
another quadripolar catheter was positioned across the tricuspid
valve to record the His bundle electrogram via right femoral vein
access. Paroxysmal supraventricular tachycardia was excluded.
The geometry of the right and left ventricle was reconstructed
using the CARTO system with a 3.5-mm tip saline-irrigated
ablation catheter (ThermoCool NaviStar, Biosense Webster). VT
was induced by stimulation of the ablation catheter in the right
ventricle (Fig. 1A, B). However, the tachycardia persisted for less
than one minute before termination, and it was not induced again
after termination.
Pace mapping was then used first in the right ventricle, and
then in the left. During mapping in the left ventricular apex, the
heart at first failed to follow the impulse, and then the stimulation
signal suddenly disappeared and the potential in the distal ablation
catheter was significantly reduced (Fig. 2). Immediately after these
findings were recognised, the catheter was slightly withdrawn.
Subsequently, a stimulus signal occurred again. However, the
ventricle still failed to respond to the stimulus signal (Fig. 2).
Almost simultaneously, the patient complained of mild chest pain.
A small amount of diluted contrast agent was then injected
via the ablation catheter lumen to identify the location of the
catheter tip. Angiography showed that the catheter had perforated
the left ventricular apex, with the tip lying immediately under
the epicardium (Fig. 3A, B). Subsequently, the ST segment in
leads V
1
to V
3
was elevated (Fig. 4A), similar to what occurs
in patients presenting with anteroseptal myocardial infarction.
However, there was no significant change in blood pressure and
heart rate in the patient and she did not complain of discomfort
or mild chest pain.
Department of Cardiology, Henan Provincial People’s
Hospital, Zhengzhou University, Zhengzhou, China
Jin-Tao Wu, MD
Department of Cardiology, Centre for Atrial Fibrillation,
Beijing Anzhen Hospital, Capital Medical University,
Beijing, China
Jian-Zeng Dong, MD,
