We report a case of septal ventricular tachycardia with previous failed ablation attempts that was successfully treated using a bipolar ablation strategy, with the significant contribution of intracardiac echocardiography (ICE). ICE was utilized to enhance procedural safety by preventing steam pops and late ventricular septal defects (VSD) and to optimize outcomes by ensuring homogeneous ablation of the septal tissue, visually confirming a transmural lesion.

Case report A 74-year-old man presented with frequent palpitations, described as “the heart beating on the neck.” He also had a history of two syncope episodes; the most recent was more than six months before his admission. By careful history taking, we found that the syncope episodes did not seem to occur as a result of vasovagal reflex. The patient’s resting electrocardiogram (ECG) showed a right bundle branch block (RBBB) pattern (Figure 1 ). Holter monitoring and exercise tests revealed a bundle branch block alternating between the right and left bundles. His echocardiogram was normal with preserved ejection fraction (EF) (66%).After this initial evaluation, he was subjected to an electrophysiological study (EPS) and the basic intervals measured were as follows: PR, 186 ms; QRS, 153 ms (RBBB); AH, 86 ms (basal); and HV, 60 ms. Atrial electrical stimulation (AES) induced a wide QRS complex tachycardia (Figure 2A ), with predominantly RBBB morphology, some of the QRS having a left bundle branch block (LBBB) pattern, and some atrial beats being blocked to the ventricles below the bundle of His (Figure 2B ).