Novel use of preprocedure imaging for planning and guidance of right atrium–to–left ventricle access for catheter ablation of ventricular tachycardia

Figures

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  Figure 1. Preprocedure noncontrast segmented electrocardiogram-gated cardiac computed tomography (CT). A: Three-dimensional reconstruction of cardiac anatomy in left anterior oblique orientation. B: Segmented axial CT slice with red arrow showing planned crossing site from right atrium (RA) to left ventricle (LV) on the inferior septal process. C: Surgeon’s view showing chosen crossing site as red tag and relationship with His region. D: Redemonstration of chosen crossing site in right anterior oblique view. AMPZ = Amplatzer plug; Ao = aorta; AVR = aortic valve replacement; CS = coronary sinus; His = His bundle anatomic region; LA = left atrium; Lead = pacing and implantable cardiac defibrillator leads; LV = left ventricle; MVR = mitral valve replacement; RA = right atrium; RV = right ventricle.

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  Figure 2. Representative imaging during right atrium (RA)–to–left ventricle (LV) access. A: Intracardiac echo image with the catheter in the RA and imaging plane across the interior septal process of the LV, with the sheath shown in contact at the intended crossing site. B: Fluoroscopic image with a wire in the LV and balloon catheter inflated across the inferior septal LV process. C: Electroanatomic map in right anterior oblique projection showing the sheath and catheter advanced from the RA (gray) to the LV (purple) with overlay of the aorta (red), coronary sinus (blue), aortic valve replacement (AVR), mitral valve replacement (MVR), and Amplatzer devices (white) and planned crossing site (green dot) from registered preprocedure computed tomography imaging. Putative His bundle location (yellow dot) is measured to be >2 cm away from the crossing site. D: Left anterior oblique projection of the same image. AMPZ = Amplatzer plug; His = His bundle anatomic region.

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  Figure 3. Left ventricle (LV) mapping and ablation following right atrium (RA)-to-LV access. A: Final map with annotation of latest activation under right ventricular pacing showing a large lateral substrate with putative lines of block (white) and channels of slowed propagation. B: Representative electrograms from the depicted position of the mapping catheter in panel A, showing late potentials. C: Color Doppler imaging on intracardiac echo after sheath removal showing a small jet of flow from the LV to RA.