Treatment of intramural ventricular tachycardia in cardiac sarcoidosis with transcoronary ethanol ablation

The patient is a 67-year-old man who had recurrent ventricular tachycardia (VT) despite treatment with amiodarone. Cardiac magnetic resonance imaging (MRI) demonstrated delayed enhancement of the mid-myocardium in the basal inferolateral wall and septum (Figure, Panel A). Cardiac Positron emission tomography–computed tomography (PET–CT) showed a perfusion defect with increased 18F-fluorodeoxyglucose uptake in the inferolateral wall, consistent with active myocardial inflammation. During electrophysiologic study, two different VT morphologies were induced, with left bundle branch block and right bundle branch block, left superior axes, respectively (Figure, Panels B and C). The VT cycle lengths were 330–400 ms. The earliest activation during VT (35 ms pre-QRS) and the best pace and entrainment maps were at the cardiac crux along the inferior interventricular septum near the posterior descending artery. The patient underwent four attempts at radiofrequency (RF) catheter ablation, including epicardial ablation, and bipolar transmural RF ablation.