Late onset of exercise induced focal ventricular tachycardia originating from the ventricular end of an A–V accessory pathway after elimination of conduction ★★★

• Remote onset exercise induced focal ventricular tachycardia (VT) arising from the ventricular end of bi-directionally conducting A–V accessory pathway that was successfully ablated previously.
• There was no documented accessory pathway related automaticity prior to the first ablation.
• There was no residual conduction across the accessory pathway after the first ablation.
• The VT morphology was similar to that of the pre-excited QRS beats noted before.
• The VT was mapped to and successfully ablated at the same site where the ventricular end of the pathway was previously ablated.
• Thus far, in all reported cases of accessory pathway related automaticity there was intact conduction over the pathway or acute injury to it. To the best of our knowledge a case similar to our patient is not reported yet.

The authors report the unique case of remote onset of exercise induced focal ventricular tachycardia in a 40-year old male patient that originated from the ventricular end of an accessory atrioventricular pathway 18 months after a successful ablation. There was no residual conduction across the pathway after the first ablation. The ventricular tachycardia (VT) was mapped to and successfully ablated at the same site where the ventricular end of the pathway was previously ablated. The VT morphology was similar to that of the pre-excited QRS beats noted before. Thus far, in all reported cases of accessory pathway related automaticity there was intact conduction over the pathway or acute injury to it. To the best of our knowledge a case similar to our patient is not yet reported.