Novel real-time automation of combined frequency and low voltage substrate mapping to guide ablation for Brugada syndrome: a case report

Abstract Background Brugada syndrome (BrS) is an inherited cardiac condition that increases the risk of sudden cardiac death (SCD) due to ventricular arrhythmias. Catheter ablation has been shown to effectively reduce recurrent ventricular fibrillation (VF) episodes through targeting of abnormal electrograms predominantly located within the anterior surface of the right ventricular outflow tract. Signal frequency mapping is an emerging concept that provides further definition of pathological ventricular substrate. Case summary A 66-year-old male with BrS was admitted to our institution with implantable cardioverter defibrillator shocks for VF. Electro-anatomical mapping (EAM) and ablation were performed utilizing a novel automated frequency-based strategy. Combined automated frequency and low voltage maps were generated to define high frequency, low voltage (HF-LVo) depolarization abnormalities within the QRS complex. Low frequency, low voltage (LF-LVo) regions from the QRS terminal notch to the T-wave offset were also identified. The combined HF-LVo and LF-LVo map areas totalled 12.4 cm2, compared to the conventional low voltage and late potential map areas, which were 44 cm2 and 27.8 cm2, respectively. The ablation strategy targeted HF-LVo and LF-LVo regions only. Following ablation, re-mapping demonstrated near complete abolition of HF-LVo and LF-LVo regions, with no inducible ventricular arrhythmias during extra-stimulation testing. During follow-up, ECG normalization was observed, with no further ventricular arrhythmias and a negative ajmaline challenge at 6 months. Discussion Catheter ablation for BrS utilizing a novel automated combined frequency and low voltage EAM approach can objectively identify relevant substrate. The results demonstrate adequate substrate modification with comparable ablation target areas to previous studies and encouraging clinical outcomes.