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Nishiwaki S, Shizuta S, Kohjitani H, Ono K. Insight from the microelectrodes in case of two different types of premature ventricular contractions originating from left ventricular summit. Indian Pacing Electrophysiol J 2024:S0972-6292(24)00052-4. [PMID: 38729242 DOI: 10.1016/j.ipej.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/30/2024] [Accepted: 05/08/2024] [Indexed: 05/12/2024] Open
Abstract
Premature ventricular contraction (PVC) is usually eliminated in the earliest activation site based on the conventional electrode of ablation catheter. However, the large size electrode may contain far-field potential. The QDOT MICRO ablation catheter has three micro electrodes with 0.33 mm electrode length, in addition to the conventional electrode with 3.5 mm electrode length. The micro electrodes can reflect only near-field potential. A 78-year-old with symptomatic frequent PVCs underwent catheter ablation. PVC-1 showed good pace-mapping in distal great cardiac vein (GCV). The local bipolar electrograms in the conventional electrode of ablation catheter preceded the PVC-QRS onset by 32 ms in distal GCV and 13 ms in left coronary cusp (LCC), but those in the micro electrodes preceded only by 13 ms both in distal GCV and LCC. PVC-1 was eliminated by radiofrequency (RF) application, not in distal GCV, but in LCC. PVC-2 showed good pace-mapping in LCC. The local bipolar electrograms in both the conventional electrode and the micro electrodes of ablation catheter preceded the PVC-QRS onset by 32 ms in LCC. PVC-2 was eliminated by RF application in LCC. Comparing the local electrograms of micro electrodes and the conventional electrodes may be important for identifying depth of the origin of PVCs.
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Affiliation(s)
- Shushi Nishiwaki
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirohiko Kohjitani
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Toba M, Nasu T, Nekomiya N, Makino T, Yokoshiki H. Bipolar radiofrequency ablation for re-entrant ventricular tachycardia of right bundle branch block and left bundle branch block morphologies with the common slow conduction zone at the left ventricular summit: a case report. Eur Heart J Case Rep 2024; 8:ytae191. [PMID: 38690559 PMCID: PMC11060111 DOI: 10.1093/ehjcr/ytae191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
Background The left ventricular (LV) summit has anatomical limitations, so the detailed mapping is difficult. Therefore, the mechanism of ventricular tachycardia (VT) originating from the LV summit is not well understood. Case summary A 70-year-old man had VTs with right bundle branch block (VT1 and VT3) and left bundle branch block (VT2) morphologies originating from the left ventricular summit (LV summit). During the VT2 and VT3, fragmented potentials, which occurred earlier than the QRS onset, were recorded from bipolar electrodes of a catheter at the anterior intraventricular vein (AIV). By pacing from right ventricular apex, constant and progressive fusion were observed. During the entrainment pacing, the fragmented potentials in the AIV catheter were activated orthodromically and those in the His bundle were activated antidromically. In addition, there were two components of the ventricular electrogram at the LV summit area with the interval of more than 100 ms during the VTs. We performed bipolar radiofrequency ablation between the LV endocardium and AIV, and the VTs became non-inducible. Discussion Non-sustained VT/premature ventricular contraction originating from LV summit is generally considered to occur due to abnormal automaticity or triggered activity. In contrast, using entrainment technique, we demonstrated that the VTs with multiple morphologies were sustained with a re-entrant mechanism. Fragmentated potentials recorded in the AIV catheter were activated orthodromically with the entrainment pacing, indicating the slowly conducting isthmus. The intramural VT substrate was also suggested with a prolonged conduction time between the two ventricular components during the VTs.
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Affiliation(s)
- Masahiro Toba
- Department of Cardiovascular Medicine, Sapporo City General Hospital, Kita-11, Nishi-13, Chuo-ku, Sapporo 060-8604, Japan
| | - Toshihiro Nasu
- Division of Medical Engineering Center, Sapporo City General Hospital, Sapporo, Japan
| | - Nobuyoshi Nekomiya
- Division of Medical Engineering Center, Sapporo City General Hospital, Sapporo, Japan
| | - Takao Makino
- Department of Cardiovascular Medicine, Sapporo City General Hospital, Kita-11, Nishi-13, Chuo-ku, Sapporo 060-8604, Japan
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital, Kita-11, Nishi-13, Chuo-ku, Sapporo 060-8604, Japan
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3
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Tashiro K, Komaki T, Ideishi A, Mohri N, Miura SI, Ogawa M. Distinct single spiky component of local abnormal ventricular activity and accurate identification of origin of premature ventricular complexes arising from left ventricular summit. HeartRhythm Case Rep 2024; 10:182-185. [PMID: 38496738 PMCID: PMC10943545 DOI: 10.1016/j.hrcr.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Affiliation(s)
- Kohei Tashiro
- Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan
- Endowed Department of Advanced Therapeutics for Cardiovascular Disease, Fukuoka University, Fukuoka, Japan
| | - Tomo Komaki
- Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan
| | - Akihito Ideishi
- Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan
| | - Noriyuki Mohri
- Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan
| | - Shin-ichiro Miura
- Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan
| | - Masahiro Ogawa
- Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan
- Endowed Department of Advanced Therapeutics for Cardiovascular Disease, Fukuoka University, Fukuoka, Japan
- Department of Clinical Laboratory Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
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Ishiguro N, Kato K, Goto H, Kametani R. Successful chemical ablation of refractory ventricular tachycardia from the left ventricular summit using the double balloon technique with chronic total occlusion percutaneous coronary intervention techniques. HeartRhythm Case Rep 2024; 10:58-62. [PMID: 38264102 PMCID: PMC10801000 DOI: 10.1016/j.hrcr.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Affiliation(s)
- Nobuo Ishiguro
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Kazuo Kato
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Hiroko Goto
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Ryosuke Kametani
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Japan
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Mages C, Steinfurt J, Rahm AK, Thomas D, Majidi R, Kehrle F, André F, Seidensaal K, Rhein B, Wengenmayer T, Gressler A, Westermann D, Herzog R, Debus J, Frey N, Lugenbiel P. Recurrent ventricular tachycardia originating from the " left ventricular summit" effectively eliminated by stereotactic irradiation - A case report. HeartRhythm Case Rep 2023; 9:802-807. [PMID: 38023678 PMCID: PMC10667122 DOI: 10.1016/j.hrcr.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Affiliation(s)
- Christine Mages
- Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
- Informatics for Life Consortium, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Johannes Steinfurt
- Department of Cardiology and Angiology, Medical Center – University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ann-Kathrin Rahm
- Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
- Informatics for Life Consortium, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Dierk Thomas
- Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
- Informatics for Life Consortium, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Reyhaneh Majidi
- Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
- Informatics for Life Consortium, University Hospital Heidelberg, Heidelberg, Germany
- Institute for Scientific Computing (IWR), Heidelberg University, Heidelberg, Germany
| | - Florian Kehrle
- Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
- InspirationLabs GmbH, Heidelberg, Germany
| | - Florian André
- Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
- Informatics for Life Consortium, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Bernhard Rhein
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Gressler
- Department of Cardiology and Angiology, Medical Center – University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center – University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Herzog
- Informatics for Life Consortium, University Hospital Heidelberg, Heidelberg, Germany
- Institute for Scientific Computing (IWR), Heidelberg University, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Norbert Frey
- Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
- Informatics for Life Consortium, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Patrick Lugenbiel
- Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
- Informatics for Life Consortium, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
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Guandalini GS. Intramyocardial Mapping of Ventricular Arrhythmias via Septal Venous Perforators: Defining the Superior Intraseptal Space. Card Electrophysiol Clin 2023; 15:39-47. [PMID: 36774135 DOI: 10.1016/j.ccep.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Left ventricular outflow tract arrhythmias that fail endocardial mapping and ablation have traditionally been labeled as originating from the epicardial left ventricular summit. Although these sometimes can be targeted from the epicardial surface of the left ventricular ostium, such approach poses significant technical challenges. A significant proportion of such arrhythmias, however, exhibit intramyocardial origin, demonstrated by mapping intraseptal branches of the anterior interventricular vein, and henceforth defined as the basal superior intraseptal space.
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Affiliation(s)
- Gustavo S Guandalini
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania - Pavilion, One Convention Avenue, Level 2 - City Side, Philadelphia, PA 19104, USA.
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7
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Kuniewicz M, Budnicka K, Dusza M, Jakob N, Cholewa N, Defonseka R, Gosnell M, Wadhwa T, Walocha J, Dobrzynski H, Hołda M. Gross anatomic relationship between the human left atrial appendage and the left ventricular summit region: implications for catheter ablation of ventricular arrhythmias originating from the left ventricular summit. J Interv Card Electrophysiol 2023; 66:301-310. [PMID: 35262858 DOI: 10.1007/s10840-022-01172-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The left ventricular summit (LVS) is a source of difficult-to-treat arrhythmias because of anatomical limitations. The aim of this study was to perform detailed research of the left atrial appendage (LAA) anatomy of cadaveric hearts to analyze their complex anatomy and coverage of the LVS. METHODS AND RESULTS Eighty human formalin fixed hearts (mean age 44.4 ± 15.5, 27.5% females) were investigated. Each LAA size, type, and its relationship to the LVS were analyzed, as well as possible access sites for mapping/ablating electrode. Four types of LAA were observed over two LVS sites that are either accessible or not. The highest coverage over an inaccessible LVS area was observed in the Broccoli type, followed by the Windsock then the Chicken Wing and finally the Cactus types; over the accessible area of the LVS was observed in the Windsock, then in the Chicken Wing, then in the Cactus, and finally in the Broccoli types. The attainable coverage for electrode access is diminished from 25 to 65% because of the complex pectinate muscles and sharp angles. The highest density of the LAA floor made by pectinate muscles can be found in the Broccoli type (p < 0.005), while the Chicken Wing had the highest number of paper-thin-like pouches. CONCLUSIONS The LAA appears to be a promising entry for ablation-qualified patients with the LV summit originate arrhythmias. The complex internal structure of the LAA may complicate ablation procedures. More prominent appendages are promising in more extensive mapping areas over the LVS.
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Affiliation(s)
- M Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland. .,Department of Electrocardiology, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland.
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Dusza
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Cholewa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - R Defonseka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - T Wadhwa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - H Dobrzynski
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - M Hołda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
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8
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Yamada T. Predictors of Successful Endocardial Ablation of Epicardial Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:15-24. [PMID: 36774132 DOI: 10.1016/j.ccep.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Endocardial catheter ablation of ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) at remote structures adjacent to the LVS may be an alternative (anatomic approach) but may not be so successful. This type of catheter ablation is successful most commonly in the left ventricular outflow tract followed by the aortic cusps and rarely in the right ventricular outflow tract. A right bundle branch block QRS morphology and anatomic distance between the earliest ventricular activation site in the coronary venous system and endocardial ablation site (<13 mm) could be predictors of a successful endocardial catheter ablation of LVS VAs.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, 420 Delaware Street Southeast, MMC 508, Minneapolis, MN 55455, USA.
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9
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Te-Rosano ALD, Chung FP, Lin YJ, Chen SA. Outcomes of Catheter Ablation of Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:85-92. [PMID: 36774140 DOI: 10.1016/j.ccep.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The left ventricular summit (LVS) is the area in the highest portion of the left ventricular epicardium, bounded by the left coronary arteries and the coronary venous circulation, and can be surrounded by thick epicardial fat that may preclude epicardial ablation. Ablation of LVS ventricular arrhythmias (VA) can be achieved from adjacent structures with good success rates. The long-term freedom from LVS VA recurrence remains variable. This article reviews the spatial and anatomic relationship of the structures surrounding the LVS, which provide vantage points for ablation, and the acute and long-term outcomes of different ablation approaches in LVS VA ablation.
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Affiliation(s)
- Abigail Louise D Te-Rosano
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan; HB Calleja Heart and Vascular Institute, St. Luke's Medical Center, 279 E. Rodriguez Sr. Avenue, Quezon City 1112, Philippines
| | - Fa-Po Chung
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan.
| | - Yenn-Jiang Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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Mori S, Hayase J, Sridharan A, Fukuzawa K, Shivkumar K, Bradfield JS. Revisiting the Anatomy of the Left Ventricular Summit. Card Electrophysiol Clin 2023; 15:1-8. [PMID: 36774131 DOI: 10.1016/j.ccep.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The left ventricular summit corresponds to the epicardial side of the basal superior free wall, extending from the base of the left coronary aortic sinus. The summit composes the floor of the compartment surrounded by the aortic root, infundibulum, pulmonary root, and left atrial appendage. The compartment is filled with thick adipose tissue, carrying the coronary vessels. Thus, the treatment of ventricular tachycardia originating from the summit is challenging, and three-dimensional understanding of this complicated region is fundamental. We revisit the clinical anatomy of the left ventricular summit with original images from the Wallace A. McAlpine collection.
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Affiliation(s)
- Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA Cardiovascular Interventional Programs, Department of Medicine, David Geffen School of Medicine at UCLA & UCLA Health System, Los Angeles, CA, USA.
| | - Justin Hayase
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA Cardiovascular Interventional Programs, Department of Medicine, David Geffen School of Medicine at UCLA & UCLA Health System, Los Angeles, CA, USA
| | - Aadhavi Sridharan
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA Cardiovascular Interventional Programs, Department of Medicine, David Geffen School of Medicine at UCLA & UCLA Health System, Los Angeles, CA, USA
| | - Koji Fukuzawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA Cardiovascular Interventional Programs, Department of Medicine, David Geffen School of Medicine at UCLA & UCLA Health System, Los Angeles, CA, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA Cardiovascular Interventional Programs, Department of Medicine, David Geffen School of Medicine at UCLA & UCLA Health System, Los Angeles, CA, USA
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11
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Shirai Y. Percutaneous Epicardial Ablation of Ventricular Arrhythmias Arising from the Left Ventricular Summit. Card Electrophysiol Clin 2023; 15:25-30. [PMID: 36774133 DOI: 10.1016/j.ccep.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The left ventricular summit (LVS) is the highest point of the left ventricular epicardium, and ventricular arrhythmias originating from this area accounts for 10% to 15% of idiopathic outflow tract ventricular arrhythmias. Direct epicardial ablation of outflow tract ventricular arrhythmias arising from the LVS is successful only in a minority of patients because of close proximity to the coronary artery or thick epicardial fat. Therefore, alternative strategies should be prioritized before performing epicardial approach. When performed, electrocardiogram characteristics suggestive of the site of origin to be the accessible area within the LVS needs be evaluated to avoid ineffective epicardial approach.
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12
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Abstract
Challenging anatomic and morphologic conditions of the left ventricular (LV) summit architecture and its surrounding sites may prevent sufficient heating of the targeted area during standard radiofrequency catheter ablation. Bipolar ablation can result in higher likelihood of efficacy for ablation of LV summit arrhythmias from inaccessible regions and increase the chance of achieving a transmural lesion. In this review, the authors describe the present approaches for bipolar ablation of the LV summit arrhythmias refractory to standard approaches.
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Affiliation(s)
- Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Anny Jagiellonki 17, Rzeszów 35-623, Poland.
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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13
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Yamada T. Techniques for Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating from the Outflow Tract and Left Ventricular Summit. Card Electrophysiol Clin 2022; 14:621-631. [PMID: 36396181 DOI: 10.1016/j.ccep.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Idiopathic ventricular arrhythmias (VAs) most commonly originate from the ventricular outflow tracts. Because the anatomy of this region is complex and some of those VA origins are intramural and epicardial, it may sometimes be difficult to locate the site of the VA origin. Meticulous mapping in multiple different locations such as the right and left ventricular outflow tracts, endocardial and epicardial sites, and above and below the aortic and pulmonic valves may be required to achieve successful catheter ablation of those VAs. Special ablation techniques may be considered to improve the outcome of catheter ablation of intramural and epicardial VAs.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA.
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14
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Stojadinović P, Wichterle D, Peichl P, Štiavnický P, Čihák R, Kautzner J. Retrograde coronary venous ethanol ablation of ventricular tachycardia in a patient after aortic valve replacement and failed both radiofrequency ablation and stereotactic radiotherapy. HeartRhythm Case Rep 2023; 9:2-5. [PMID: 36685688 DOI: 10.1016/j.hrcr.2022.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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15
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Nakamura K, Sasaki T, Kimura K, Haraguchi Y, Minami K, Naito S. Successful elimination of ventricular arrhythmias by radiofrequency ablation within the left ventricular summit communicating vein using a 5F ablation catheter. HeartRhythm Case Rep 2022; 8:771-775. [PMID: 36618603 PMCID: PMC9811025 DOI: 10.1016/j.hrcr.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Kohki Nakamura
- Address reprint requests and correspondence: Dr Kohki Nakamura, Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma 371-0004 Japan.
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Wolfes J, Ellermann C, Köbe J, Lange PS, Leitz P, Rath B, Willy K, Güner F, Frommeyer G, Eckardt L. [Anatomy of the left ventricle for endocardial ablation]. Herzschrittmacherther Elektrophysiol 2022; 33:161-174. [PMID: 35556156 DOI: 10.1007/s00399-022-00859-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/15/2022] [Indexed: 06/15/2023]
Abstract
As with all cardiac interventions, performing left ventricular ablation requires profound knowledge of cardiac anatomy. The aim of this article is to provide an overview of left ventricular anatomy and to characterize complex and clinically relevant structures from an electrophysiologist-centered perspective. In addition to the different access routes, the trabecular network, the left ventricular outflow tract, and the left ventricular conduction system, complex anatomical structures such as the aortomitral continuity and the left ventricular summit are also explained. In addition, this article offers multiple clinical examples that combine ECG, anatomy, and electrophysiologic study.
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Affiliation(s)
- Julian Wolfes
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland.
| | - Christian Ellermann
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Julia Köbe
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Philipp S Lange
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Patrick Leitz
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Benjamin Rath
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Kevin Willy
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Fatih Güner
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Gerrit Frommeyer
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Lars Eckardt
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
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17
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Çinier G, Hayıroğlu Mİ, Özcan KS, Pay L, Tekkeşin Aİ, Gürkan K. The use of ivabradine in a patient with idiopathic ventricular arrhythmia originating from the left ventricular summit. J Electrocardiol 2022; 71:32-36. [PMID: 35026679 DOI: 10.1016/j.jelectrocard.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/19/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
Idiopathic ventricular arrhythmias (VA) are common and treatment options include anti-arrhythmic drugs (AAD) or catheter ablation. Patients presenting with idiopathic VA which is originating from the left ventricular summit (LVS) poses a particular challenge as the success for catheter ablation is low and AAD's may not be used long-term due to side effects. Ivabradine is an inhibitor of funny current (If) in cardiac pacemaker cells by blocking hyperpolarization-activated cyclic nucleotide-gated (HCN). In the present case, we reported the use of ivabradine in treatment of idiopathic VA which was originated from LVS and was resistant to multiple AAD's and catheter ablation.
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Affiliation(s)
- Göksel Çinier
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training Hospital, Istanbul, Turkey
| | - Mert İlker Hayıroğlu
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training Hospital, Istanbul, Turkey
| | - Kazım Serhan Özcan
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training Hospital, Istanbul, Turkey
| | - Levent Pay
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training Hospital, Istanbul, Turkey.
| | - Ahmet İlker Tekkeşin
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training Hospital, Istanbul, Turkey
| | - Kadir Gürkan
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training Hospital, Istanbul, Turkey
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18
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Bustillos-García GA, Garcia A, Cueva-Parra A, Nava S. Radiofrequency catheter ablation of ventricular tachycardia from the left ventricular summit in congenital heart disease. J Interv Card Electrophysiol 2021; 62:505-506. [PMID: 34417935 DOI: 10.1007/s10840-021-01046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022]
Abstract
Tetralogy of Fallot (ToF) is one of the most prevalent cyanotic congenital heart disease (CHD). Subsequent to the introduction of surgical repair, long-term outcomes for patients with ToF have improved significantly. Pulmonary atresia with ventricular septal defect (PA-VSD) may be considered as an extreme form of classic ToF. Surgical repair not only corrects the haemodynamic but also creates scars that will be source for ventricular arrhythmias. Patients with tetralogy of Fallot are at risk for ventricular arrhythmias and sudden cardiac death. We present the successful treatment of a 7-years-old child with history of PA-VSD treated by surgical correction and ventricular tachycardia from an unusual anatomic place in the left ventricle summit (LVS), using catheter ablation.
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Affiliation(s)
- Gabriela A Bustillos-García
- Electrocardiolgy Department, Instituto Nacional de Cardiología Ignacio Chávez", Juan Badiano, 1, Col. Sección XVI, C.P. 14080, Mexico City, Mexico
| | - Alan Garcia
- Electrocardiolgy Department, Instituto Nacional de Cardiología Ignacio Chávez", Juan Badiano, 1, Col. Sección XVI, C.P. 14080, Mexico City, Mexico
| | - Angel Cueva-Parra
- Electrocardiolgy Department, Instituto Nacional de Cardiología Ignacio Chávez", Juan Badiano, 1, Col. Sección XVI, C.P. 14080, Mexico City, Mexico
| | - Santiago Nava
- Electrocardiolgy Department, Instituto Nacional de Cardiología Ignacio Chávez", Juan Badiano, 1, Col. Sección XVI, C.P. 14080, Mexico City, Mexico.
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19
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Tavares L, Fuentes S, Lador A, Da-Wariboko A, Wang S, Schurmann PA, Dave AS, Valderrábano M. Venous anatomy of the left ventricular summit: Therapeutic implications for ethanol infusion. Heart Rhythm 2021; 18:1557-1565. [PMID: 33989783 DOI: 10.1016/j.hrthm.2021.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Venous ethanol ablation (VEA) is effective for treatment of left ventricular (LV) summit (LVS) arrhythmias. The LVS venous anatomy is poorly understood and has inconsistent nomenclature. OBJECTIVE The purpose of this study was to delineate the LVS venous anatomy by selective venography and 3-dimensional (3D) mapping during VEA and by venous-phase coronary computed tomographic angiography (vCTA). METHODS We analyzed (1) LVS venograms and 3D maps of 53 patients undergoing VEA; and (2) 3D reconstructions of 52 vCTAs, tracing LVS veins. RESULTS Angiography identified the following LVS veins: (1) LV annular branch of the great cardiac vein (GCV) (19/53); (2) septal (rightward) branches of the anterior ventricular vein (AIV) (53/53); and (3) diagonal branches of the AIV (51/53). Collateral connections between LVS veins and outflow, conus, and retroaortic veins were common. VEA was delivered to target arrhythmias in 38 of 53 septal, 6 of 53 annular, and 2 of 53 diagonal veins. vCTA identified LVS veins (range 1-5) in a similar distribution. GCV-AIV transition could either form an angle close to the left main artery bifurcation (n = 16; 88° ± 13°) or cut diagonally (n = 36; 133°±12°) (P ≤.001). Twenty-one patients had LV annular vein. In 28 patients only septal LVS veins were visualized in vCTA, in 2 patients only diagonal veins and in 22 patients both septal and diagonal veins were seen. In 39 patients the LVS veins reached the outflow tracts and their vicinity. CONCLUSION We provide a systematic atlas and nomenclature of LVS veins related to arrhythmogenic substrates. vCTA can be useful for noninvasive evaluation of LVS veins before ethanol ablation.
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Affiliation(s)
- Liliana Tavares
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Stephanie Fuentes
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Adi Lador
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Akanibo Da-Wariboko
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Sufen Wang
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Paul A Schurmann
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Amish S Dave
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas.
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20
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Efremidis M, Vlachos K, Bazoukis G, Frontera A, Martin CA, Dragasis S, Valkanas K, Letsas KP. Novel technique targeting left ventricular summit premature ventricular contractions using radiofrequency ablation through a guidewire. HeartRhythm Case Rep 2021; 7:134-8. [PMID: 33786305 DOI: 10.1016/j.hrcr.2020.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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21
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Kawata H, Yamada T, Karanam S, Reddy R. Intracoronary artery mapping and 3-dimensional visualization of the coronary arteries with a 0.014 inch guidewire in catheter ablation of left ventricular summit premature ventricular contractions. HeartRhythm Case Rep 2020; 6:914-917. [PMID: 33365238 PMCID: PMC7749218 DOI: 10.1016/j.hrcr.2020.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hiro Kawata
- Peacehealth Sacred Heart Medical Center, Springfield, Oregon
| | - Takumi Yamada
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | - Sree Karanam
- Peacehealth Sacred Heart Medical Center, Springfield, Oregon
| | - Ramakota Reddy
- Peacehealth Sacred Heart Medical Center, Springfield, Oregon
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22
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Aksan G. Catheter Ablation of Left Ventricular Summit Arrhythmia in a Patient with Critical Coronary Artery Stenosis: A Sequential Approach. J Innov Card Rhythm Manag 2020; 11:4266-4271. [PMID: 33123415 PMCID: PMC7588238 DOI: 10.19102/icrm.2020.111004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022] Open
Abstract
The left ventricular (LV) summit is the usual source of epicardial idiopathic premature ventricular contractions (PVCs). A 56-year-old male patient presented to the cardiology outpatient clinic with palpitations and dyspnea. Twelve-lead electrocardiography performed on admission revealed monomorphic PVCs with precordial QRS transition in the V1 derivation and an rS pattern in the D1 derivation and inferior axis. An electrophysiology study and ablation procedure were planned. Activation mapping guided by a three-dimensional electroanatomic system was conducted to identify the earliest site of ventricular activation of the PVCs. During the PVCs, the earliest ventricular activation was observed within the great cardiac vein (GCV) and preceded the QRS onset by 37 ms. Coronary angiography was performed before ablation in the coronary venous system (CVS) to assess the distance from the coronary artery, which showed severe stenosis in the left circumflex artery. Then, percutaneous coronary intervention was performed to address the left circumflex artery stenosis. Anatomic catheter ablation was performed in the aortic cusp and endocardial LV outflow tract, the sites adjacent to the LV-summit PVC origin. However, successful ablation could not be achieved. Subsequently, an irrigated radiofrequency current was delivered in the GCV for 60 seconds, with the power being gradually increased to 30 W and with an irrigation flow rate of 30 mL/min. After ablation, under isoproterenol infusion and burst pacing from the right ventricle, no PVC or ventricular tachycardia was observed. Special precautions should be taken to avoid coronary artery damage during ablation from distal CVS. This approach may increase the success of ablation and avoid potential complications.
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Affiliation(s)
- Gökhan Aksan
- Department of Cardiology, Samsun Education and Research Hospital, Samsun, Turkey
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23
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Kuniewicz M, Krupiński M, Gosnell M, Budnicka K, Jakob N, Karkowski G, Urbańczyk-Zawadzka M, Lelakowski J, Walocha J. Applicability of computed tomography preoperative assessment of the LAA in LV summit ablations. J Interv Card Electrophysiol 2020; 61:357-363. [PMID: 32666410 PMCID: PMC8324620 DOI: 10.1007/s10840-020-00817-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/29/2020] [Indexed: 11/12/2022]
Abstract
Purpose Ventricular arrhythmias originating from the left ventricular summit (LVS) may present with challenges for catheter ablation. Recently, the left atrial appendage (LAA) became a new vantage point for mapping and ablating arrhythmias from that region, but data of possible usefulness is limited. Methods From September to December 2019, we retrospectively analyzed 48 consecutive patient hearts (20 male; mean age 57.9y ± 11.56) undergoing diagnostic coronary vessel imaging in 64 dual-source computer tomography angiography (CTA). Distances from the LAA to the LVS, LAA shape type, and coronary arteries in the LVS region were measured. Also, we compared the true LVS area from CTA with a calculated formula derived from LVS definition. Results The mean LVS area calculated from the formula was 291.58 mm2 (± 115.5) while the true area calculated from CT was 263.33 mm2 (± 99.49) (p = 0.44). The mean inaccessible area was 133.42 mm2 (± 72.89), accessible 95.67 mm2 (± 72.77). The mean LAA coverage over LVS was 196.08 mm2—which is approximately 75% of LVS size in general. The most common LAA shape was chicken wing (50%); windsock has the highest accessible area coverage on average (80.23%), followed by chicken wing (59.88%), broccoli (47.72%), and cactus (46.98%). The mean distance from LAA to the surface was 5.14 mm (1.5 to 10 mm) and was not correlated with BMI. LAA has a 98% coverage over the point of transition between the great cardiac vein and anterior interventricular vein. Conclusion Angio-CT assessment of the LAA over the LVS structures may be helpful in decision making before an ablation procedure. LAA appears to be a promising mapping approach in LVS arrhythmias.
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Affiliation(s)
- Marcin Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland. .,Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland.
| | - M Krupiński
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - G Karkowski
- Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - M Urbańczyk-Zawadzka
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - J Lelakowski
- Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
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24
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Kodali S, Santangeli P, Garcia FC. Mapping and Ablation of Arrhythmias from Uncommon Sites (Aortic Cusp, Pulmonary Artery, and Left Ventricular Summit). Card Electrophysiol Clin 2019; 11:665-674. [PMID: 31706473 DOI: 10.1016/j.ccep.2019.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite advances in our understanding of the relevant anatomy and mapping and catheter ablation techniques of idiopathic outflow tract ventricular arrhythmias, challenging sites for catheter ablation remain the aortic cusps, pulmonary artery, and notably the left ventricular summit. A systematic approach should be used to direct mapping efforts efficiently between endocardial, coronary venous, and epicardial sites. Foci at the left ventricular summit, particularly intraseptal and at the inaccessible epicardial region, remain difficult to reach and when percutaneous techniques fail, surgical ablation remains an option but with risk of late coronary artery stenosis.
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Affiliation(s)
- Santhisri Kodali
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA
| | - Fermin C Garcia
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA.
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25
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Candemir B, Baskovski E, Duzen V, Coskun F, Vurgun K, Goksuluk H, Ozyuncu N, Kurklu ST, Altin T, Akyurek O, Erol C. Late elimination of challenging idiopathic ventricular arrhythmias originating from left ventricular summit by anatomical ablation. Indian Pacing Electrophysiol J 2019; 19:114-118. [PMID: 30822513 PMCID: PMC6531642 DOI: 10.1016/j.ipej.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/10/2019] [Accepted: 02/14/2019] [Indexed: 12/02/2022] Open
Abstract
Ablation of premature ventricular complexes (PVCs) originating from left ventricular outflow tract (LVOT)/left ventricular summit (LVS) is challenging with considerable rate of failure. Recently, in a novel approach to ablation of these arrythmias, application of radiofrequency energy to anatomically opposite sites of presumed origin of arrythmia, has been associated with moderate procedure success. Although late elimination of PVCs that are persistent following an ablation procedure has been previously reported, this observation has not been studied sufficiently. In this report, firstly, we present three cases of lately eliminated LVS PVCs, then, we discuss possible mechanism of this observation and conclude that after an initial failed attempt of anatomic ablation, operators may choose a period of watchful waiting before attempting a redo procedure.
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Affiliation(s)
- Basar Candemir
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Emir Baskovski
- Ankara University, Cardiology Department, Ankara, Turkiye.
| | - Veysel Duzen
- Gaziantep Ersin Arslan Research Hospital, Cardiology Department, Gaziantep, Turkiye
| | - Firat Coskun
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Kutay Vurgun
- Ankara University, Cardiology Department, Ankara, Turkiye
| | | | - Nil Ozyuncu
- Ankara University, Cardiology Department, Ankara, Turkiye
| | | | - Timucin Altin
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Omer Akyurek
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Cetin Erol
- Ankara University, Cardiology Department, Ankara, Turkiye
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26
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Tung R, Liu Q, Jiang R, Jiang C. Nonionic irrigated radiofrequency ablation of refractory incessant ventricular tachycardia via great cardiac vein. HeartRhythm Case Rep 2018; 4:572-575. [PMID: 30581735 PMCID: PMC6301884 DOI: 10.1016/j.hrcr.2018.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Roderick Tung
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Chicago, Illinois
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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27
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Banavalikar B, Shenthar J. Electrocardiographic characteristics and mapping approach of ventricular arrhythmias originating from the left ventricular summit. J Electrocardiol 2018; 51:687-90. [PMID: 29997014 DOI: 10.1016/j.jelectrocard.2018.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 11/21/2022]
Abstract
The left ventricular summit is the most common site of idiopathic epicardial ventricular tachycardia (VT). We report a case of a 48-yr-old lady who presented with VT of RBBB configuration, inferior axis and delayed initial activation. During electrophysiological study, local activation in the distal great cardiac vein (GCV) preceded surface QRS by 56 ms whereas mapping in the aortic sinuses and left ventricular outflow tract endocardially revealed late activation. Ablation in the distal GCV with an irrigated catheter successfully terminated the tachycardia. The 12‑lead electrocardiogram is an invaluable tool for predicting the VT focus and planning the mapping strategy.
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28
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Kato K, Tanaka A, Hasegawa S, Kametani R. Successful ethanol injection into the anterior interventricular cardiac vein for ventricular premature contractions arising from the left ventricular summit. HeartRhythm Case Rep 2018; 4:310-313. [PMID: 30023279 PMCID: PMC6050439 DOI: 10.1016/j.hrcr.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kazuo Kato
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Akimitsu Tanaka
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Shin Hasegawa
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Japan
| | - Ryosuke Kametani
- Department of Cardiology, Nagoya Tokushukai General Hospital, Kasugai, Japan
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29
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Dandamudi S, Kim SS, Verma N, Malaisrie SC, Tung R, Knight BP. Left ventricular pseudoaneurysm as a complication of left ventricular summit premature ventricular contraction ablation. HeartRhythm Case Rep 2017; 3:268-271. [PMID: 28736711 PMCID: PMC5509911 DOI: 10.1016/j.hrcr.2017.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Sanjay Dandamudi
- Department of Medicine, Division of Cardiology, Northwestern University, Chicago, Illinois
| | - Susan S Kim
- Department of Medicine, Division of Cardiology, Northwestern University, Chicago, Illinois
| | - Nishant Verma
- Department of Medicine, Division of Cardiology, Northwestern University, Chicago, Illinois
| | - S Chris Malaisrie
- Department of Surgery, Division of Cardiac Surgery, Northwestern University, Chicago, Illinois
| | - Roderick Tung
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois
| | - Bradley P Knight
- Department of Medicine, Division of Cardiology, Northwestern University, Chicago, Illinois
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30
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Zheng C, Li J, Li J, Zhou DP, Li XW, Wu SJ, Lin JF. Approach selection of radiofrequency catheter ablation for ventricular arrhythmias originating from the left ventricular summit: potential relevance of Pseudo Delta wave, Intrinsicoid deflection time, maximal deflection index. BMC Cardiovasc Disord 2017; 17:140. [PMID: 28558750 PMCID: PMC5450141 DOI: 10.1186/s12872-017-0575-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ventricular arrhythmias (VAs) originating from the left ventricular summit is a challenge for radiofrequency catheter ablation (RFCA). The present study aimed to investigate the appropriate RFCA strategy for VAs originating from the left ventricular summit. METHODS Forty-five consecutive patients with VAs arising from the left ventricular summit were successfully ablated at our cardiac electrophysiology center and reviewed in the study. RESULTS Thirty-two cases of VAs were eliminated in the left ventricular endocardium by retrograde transaortic (n = 22, 22/45, 48.9%) or antegrade transseptal (n = 10, 10/45, 22.2%) approaches, the other 13 cases were eliminated in the left ventricular epicardium by distal great cardiac vein (DGCV) approach (n = 13, 13/45, 28.9%). Though these VAs were similar in electrocardiographic (ECG) morphology, the pseudo delta waves (PDW), intrinsicoid deflection time (IDT), maximal deflection index (MDI) differed among them, PDW >53 ms, IDT > 74 ms, MDI > 0.45 strongly indicated that ablating left ventricular summit VAs by DGCV approach. During mean follow-up of 19.5 ± 13.2 (range, 3-60) months, 2 (4.4%) patients experienced VAs recurrence. CONCLUSION This retrospective study showed that VAs of left ventricular summit origin can be effectively cured with RFCA. For these VAs, prolonged PdW, IDT, MDI indicating RFCA by DGCV approach can be attempted firstly.
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Affiliation(s)
- Cheng Zheng
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Jin Li
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Jia Li
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - De-Pu Zhou
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Xiao-Wei Li
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Shu-Jie Wu
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Jia-Feng Lin
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China.
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Kumar S, Tedrow UB, Stevenson WG. Ventricular Arrhythmias from the Left Ventricular Summit: Critical Importance of Anatomy, Imaging, and Detailed Mapping to Allow Safe and Effective Ablation. Card Electrophysiol Clin 2016; 8:89-98. [PMID: 26920176 DOI: 10.1016/j.ccep.2015.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Ventricular arrhythmias arising from the region of the left ventricular summit can be challenging for catheter-based percutaneous ablation. A detailed knowledge of the anatomy of this region and the need of high-density mapping of surrounding structures are critical in ensuring safe and effective ablation. This case-based review focuses on the particular challenges with ablation in this region.
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Affiliation(s)
- Saurabh Kumar
- Arrhythmia Service, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Usha B Tedrow
- Arrhythmia Service, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - William G Stevenson
- Arrhythmia Service, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Abstract
The left ventricular summit is a common site of origin of idiopathic ventricular arrhythmias. These arrhythmias are most commonly ablated within the coronary venous system or from other adjacent structures, such as the right ventricular and left ventricular outflow tract or coronary cusp region. When ablation from adjacent structures fails, a percutaneous epicardial approach can be considered, but is rarely successful in eliminating the arrhythmias due to proximity to major coronary vessels and/or epicardial fat.
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Affiliation(s)
- Pasquale Santangeli
- Cardiovascular Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - David Lin
- Cardiovascular Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Lin CY, Chung FP, Lin YJ, Chong E, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chang YT, Chen YY, Chen CK, Chiou CW, Chen SA, Tsao HM. Radiofrequency catheter ablation of ventricular arrhythmias originating from the continuum between the aortic sinus of Valsalva and the left ventricular summit: Electrocardiographic characteristics and correlative anatomy. Heart Rhythm 2015; 13:111-21. [PMID: 26304712 DOI: 10.1016/j.hrthm.2015.08.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radiofrequency ablation of ventricular arrhythmias (VAs) originating from the continuum between the aortic sinus of Valsalva (ASV) and the left ventricular (LV) summit is a challenge. OBJECTIVES The objectives of this study were to investigate the electrocardiographic, electrophysiological, and anatomical characteristics of VAs and to develop an algorithm for predicting the successful ablation site. METHODS We recruited 66 patients (mean age, 47 ± 15 years; 42 male patients) with symptomatic VAs originating from the continuum between the ASV and the LV summit who underwent radiofrequency ablation. Patients were classified into 4 groups (group 1: ASV, n = 20; group 2: subvalvular region, n = 15; group 3: great cardiac vein/anterior interventricular vein [GCV/AIV], n = 16; group 4: epicardium requiring pericardial access, n = 15). The QRS morphological characteristics of VAs were compared between the 4 groups. RESULTS Electrocardiographic analysis revealed that the aVL/aVR Q-wave ratio is useful in the prediction of successful ablation sites in the ASV, subvalvular area, GCV/AIV, and epicardium requiring pericardial access at cutoff values of ≤1.415, 1.416-1.535, 1.536-1.740, and >1.740, respectively. The aVL/aVR Q-wave ratio was well correlated with the distance between the successful ablation site and the tip of the LV summit. A distance of >18.9 mm and an LV myocardial thickness of >9.1 mm predicted the need for the epicardial or GCV/AIV approaches. There were no major procedural complications. Eight patients (12.1%) developed VA recurrence during a mean follow-up of 15.9 months (interquartile range 9.2-24.2 months). CONCLUSION The aVL/aVR Q-wave ratio is a useful parameter for predicting the successful ablation sites of VAs originating from the continuum between the ASV and the LV summit.
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Affiliation(s)
- Chin-Yu Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Eric Chong
- Division of Cardiology, Department of Medicine, Alexandra Hospital, Jurong Health, Singapore
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yao-Ting Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yun-Yu Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chun-Ku Chen
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chuen-Wang Chiou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
| | - Hsuan-Ming Tsao
- Division of Cardiology, National Yang-Ming University Hospital, I-Lan, Taiwan.
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Kimura T, Takatsuki S, Fukumoto K, Nishiyama N, Aizawa Y, Miyoshi S, Fukuda K. Idiopathic ventricular tachycardia cured by radiofrequency application from the distal great cardiac vein and the left coronary cusp. Heart Lung Circ 2013; 23:193-6. [PMID: 23731982 DOI: 10.1016/j.hlc.2013.04.124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/19/2013] [Accepted: 04/27/2013] [Indexed: 10/26/2022]
Abstract
A 79 year-old male without structural heart disease suffered from drug refractory ventricular tachycardia (VT). VTs and premature ventricular complexes (PVCs) with the same morphology occurred incessantly with a concordant R pattern in chest leads and a tall R in Lead II, III, and aVF. The origin was expected to be near the left epicardial ventricular outflow tract (LVOT), which was termed the left ventricular summit area. Pace-mapping from the LVOT and the left coronary cusp (LCC) did not match well with the QRS morphology of the PVC. A good match was obtained from the distal great cardiac vein (GCV), and radiofrequency (RF) delivery eliminated the PVC and VT. However, the PVC recurred four times upon cessation of RF delivery. By placing an ablation catheter at the LCC, we obtained pace-mapping showing two different types of QRS morphologies; one was an rS pattern in V1, and the other was an R pattern in V1 with a longer stimulus to QRS interval, which was a nearly perfect match to the PVC. RF application to the LCC permanently eliminated PVCs and VTs. Several VTs from the epicardial LVOT can be cured by RF application from both the distal GCV and the LCC.
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Affiliation(s)
- Takehiro Kimura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Kotaro Fukumoto
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Nobuhiro Nishiyama
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyasu Aizawa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shunichiro Miyoshi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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