Ventricular Tachycardia Ablation via Stylet-Driven Lead–Guided Transventricular Access in a Patient with Mechanical Aortic and Mitral Valve Prostheses

Access to the left ventricle for catheter-based ventricular tachycardia ablation is particularly challenging in patients with mechanical prosthetic valves in both the aortic and mitral positions because conventional retrograde aortic and transseptal approaches are not feasible. We report a 67-year-old man with nonischemic cardiomyopathy, chronic kidney disease, double mechanical valve prostheses, and electrical storm due to recurrent monomorphic ventricular tachycardia. Left ventricular access was achieved using a stylet-driven pacing lead implanted with a left bundle branch area pacing technique to guide transventricular septal entry under fluoroscopic and electrocardiographic guidance. Ventricular tachycardia induction before detailed mapping was not tolerated because of hemodynamic deterioration; therefore, a substrate-based ablation strategy was adopted. Ablation targeted late potentials and abnormal electrograms within the low-voltage scar region. A small residual ventricular septal defect was detected after the procedure and decreased in size during follow-up without clinical sequelae. No recurrent ventricular tachycardia episodes or implantable cardioverter-defibrillator therapies occurred during follow-up. This case illustrates a feasible lead-guided transventricular access strategy for ventricular tachycardia ablation in a selected patient with a “no-entry left ventricle,” while emphasizing the importance of careful patient selection, procedural planning, and postprocedural surveillance.

Keywords: Left bundle branch area pacing, mechanical valves, transventricular access, ventricular tachycardia.