The prototypical substrate for reentrant ventricular tachycardia (VT) is post-myocardial infarction (MI) scar. Catheter ablation is an important therapeutic option for recurrent VT but sometimes it is not effective despite the technical advances. Here we describe the case of a 60-year-old man who suffered a MI in 1998 and presented with recurrent arrhythmic storms during his long-term follow-up. Twenty years later, he underwent two catheter ablations with bipolar electroanatomic voltage mapping (EVM) demonstrating only an area of low voltages in the lateral left ventricular free wall. Both procedures were unsuccessful and the patient eventually underwent cardiac transplantation in 2019. Pathology examination revealed circumferential subendocardial scar with hypertrabeculation, so that the reentry substrate was unreachable by ablation with the use of standard techniques. The comparison of EVM findings with the morphologic ones in patients with chronic ischemic heart disease can help to better understand the feasibility and effectiveness of VT substrate ablation.

Acute myocardial infarction (MI) is characterized by a wavefront extension of myocardial necrosis from the endocardium toward the epicardium in the territory supplied by the culprit coronary lesion [1,2]. The fibrous healing of the MI can alter impulse propagation and represent a substrate for scar-related reentrant ventricular tachycardia (VT).

In patients with left ventricular (LV) dysfunction and VT recurrences, catheter ablation is a consolidated therapeutical strategy [3]. We herein report the clinicopathological findings in a patient with chronic post-MI ischemic heart disease suffering from recurrent electrical storms who required heart transplantation after two VT ablation procedures.

A 60-year-old man suffered from an anterior MI in 1998 at the age of 40. Risk factors for coronary artery disease included hypertension and hypercholesterolemia. No family history for cardiovascular disease was reported. He was initially treated with medical therapy and thereafter underwent surgery with a coronary artery bypass grafting with internal mammary artery on the left anterior descending branch and saphenous vein graft on the posterior descending artery. In 2005, he had also

Post-MI chronic ischemic heart disease is frequently burdened by reentrant ventricular arrhythmias. Radiofrequency ablation of the reentry circuits is an established therapeutical strategy with suboptimal success rate and VT recurrences. In patients with a long-standing history of nontransmural MI, LV remodeling may lead to a hypertrabeculated appearance of the subendocardial region, with ischemic scars mimicking a mid-myocardial stria.

In such cases, VT substrate might not be accessible for

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