Enveloped Ablation: A Strategy for Managing Outflow Tract PVCs With an R Wave Pattern Break in Lead V2

Figures

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  Figure 1. Electrocardiogram. Premature ventricular contractions exhibiting an inferior axis, left bundle branch block type morphology, and transition zone in V3–V4. An enlarged view of Leads V1–V3 is provided for clarity. A marked reduction in the R wave amplitude was noted in Lead V2, compared with Leads V1 and V3, and is highlighted with red arrows to illustrate the pattern break.

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  Figure 2. Ablation catheter electrogram and activation mapping. A 2.6-Fr electrode catheter was placed in the anterior interventricular vein (AIV), as indicated by the orange arrows. The AIV region demonstrated the earliest activation relative to the onset of the QRS complex, occurring at −24 ms. Detailed mapping of the right ventricular outflow tract (RVOT), left ventricular outflow tract (LVOT), and aortic sinus (AS) was conducted using an ablation catheter. The earliest activation site identified by the mapping was in the RVOT (−10 ms), followed by the LVOT (−7 ms) and AS (+5 ms). The red tags mark the ablation points. The white tag indicates the earliest PVC site in the AIV.

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  Figure 3. Ablation procedure and graphical schema. Successful ablation sites. (a) First, ablation was started from the right ventricular outflow tract (RVOT) region (20 W for 120 s). (b) Additional ablation was started from the aortic sinus (AS) region (25 W for 65 s). (c) Finally, additional ablation was started from the left ventricular outflow tract (LVOT) region (30 W for 90 s), achieving the suppression of the PVCs, and the procedure was ended. (d) Graphical schema. AS, aortic sinus; LAO, left anterior oblique view; LVOT, left ventricular outflow tract; RAO, right anterior oblique view; RVOT, right ventricular outflow tract.