Catheter Ablation of Parahisian Premature Ventricular Complexes From the Right Sinus of Valsalva

Figures

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  Figure 1. Preprocedure late gadolinium cardiac enhanced magnetic resonance imaging. Preprocedural imaging was obtained in all patients. Short axis slices are shown in two patients (Panel A and B) demonstrating intramural scar (yellow arrows) in the basal anteroseptal segments in the parahisian region extending toward the outflow tract. These patients had parahisian PVCs successfully ablated from within the sinus of Valsalva (Figures 2 and 3).

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  Figure 2. Ablation of parahisian premature ventricular complex. Electroanatomic map with activation data taken from within the left ventricle and right sinus of Valsalva is shown, three‐dimensional reconstruction and overlay of the late‐gadolinium enhanced cardiac magnetic resonance imaging (Figure 1A) is shown in yellow (Pane B). Isochronal maps are shown with early sites of activation shown in red near the parahisian region, located within 10 mm of the his cloud. Presystolic signals from the left ventricle (Panel C) are shown, pace maps in this region were poor and ablation here had no impact on the clinical PVC and resulted in junctional tachycardia. Within the RCC (Panel A), far‐field, low voltage signals at the site of the catheter position shown in Panel B demonstrated similar presystolic timing. There was noncapture in this areas; however, ablation here and at yellow tags resulted in the elimination of the PVC. RCC, right coronary cusp. LVa, left ventricular apex.

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  Figure 3. Ablation of parahisian premature ventricular complex. Electroanatomic map with activation data taken from within the right ventricle and right sinus of Valsalva is shown (Panel B). Isochronal maps are shown with early sites of activation in the right ventricle near the his cloud (yellow tags). Pace maps were poor in this region; ablation in the right ventricle (red tags) resulted in partial suppression of the PVC and temporary heart block which recovered after cessation of ablation. Mapping within the right sinus of Valsalva was performed, demonstrating far‐field, low‐voltage signals (Panel C). Despite proximity to the his cloud (4 mm), ablation here resulted in elimination of the premature ventricular complex without conduction disturbances. Preprocedure late gadolinium enhanced cardiac magnetic resonance demonstrated multifocal scar, including intramural basal anteroseptal scar near the arrhythmia site of origin (Figure 1 Panel B).

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  Figure 4. Anatomic relationship of the sinus and Valsalva and the cardiac conduction system. Panel A: Transillumination of a prepared heart displayed in the right anterior oblique view is shown. Dissection has been performed to reveal a sectional plane of mid‐line structures. The penetrating bundle and nonbranching sections of the bundle of his extend through the membranous septum and crest of the ventricular septum, which lay in close proximity to the non and right sinuses of Valsalva. Panel B: Transillumination of a second prepared heart is displayed in the left posterior oblique view. Dissection has been performed to reveal midline structures. The endocardial portion of the left bundle branch along with anterior (1), septal (2), and posterior (3) fascicles are shown inferior to the membraneous septum in close proximity to sinus of valsalva. R, right coronary sinus. N, noncoronary sinus. LA, left atrium. LV, left ventricle. MV, mitral valve. Panel A used with permission from Mori et al. [10] (https://creativecommons.org/licenses/by-nc-nd/4.0/). Panel B used and modified with permission from Cabera et al. [11] (https://creativecommons.org/licenses/by-nc-nd/4.0/).