Idiopathic Ventricular Arrhythmias Originating from Different Portions of the Coronary Venous System: Prevalence, Electrocardiographic Characteristics, Catheter Ablation, and Complications

Figures

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  Figure 1. Example of a successful ablation of ventricular tachycardia (VT) originating from the posterior lateral vein (PLV). (A) Twelve-lead ECG morphology of the clinical VT. R wave in lead I, QS wave on leads II, III and aVF, r wave in lead V1, Rs wave on leads V5 and V6. (B) The local ventricular activation time recorded at the posterior wall of the endocardial mitral annulus (endo-MA) preceded the onset of the QRS complex by 43 ms and pacing this site led to a 95.6% concordance with the QRS complex of VT. (C) Cessation of the target VT is not observed within the 30s after radiofrequency initiation (pink dots in (E)). (D) Another local ventricular activation time recorded at PLV (the posterior wall of epicardium mitral annulus) preceded the onset of the QRS complex by 58 ms. (E) The fluoroscopic position of the successful ablation site was in the PLV. (F) Ablation was repeated at 43 °C, 30 W with a 60 mL/min irrigation rate. Cessation of the target VT was observed 15 s after radiofrequency initiation (red dots in Figure 1E). LAO = left anterior oblique; PA: postero-anterior. ABL-d, intracardiac bipolar electrograms; PLV, posterior lateral vein; CS, coronary sinus.

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  Figure 2. The architecture of the coronary venous system (CVS). (A,C), schematic view of the CVS; (B), posterior-anterior view of the endocardial and epicardial mitral annulus; (D), coronary venography allows clear visualization of the coronary venous architecture; (E), CT angiography of the anterior wall of the heart shows the anatomical relationship to the left anterior descending coronary artery (LAD) and the left circumflex coronary artery (LCX). Abbreviation: CS, coronary sinus; GCV, great cardiac vein; DGCV1, the distal great cardiac vein local in epicardium of the anterior lateral wall of the mitral annulus; DGCV2, the distal great cardiac vein proximal to the origin of AIV. MCV, middle cardiac vein; SCV, small cardiac vein; AIV, anterior interventricular vein; Summit-CV, the communicating vein in left ventricular Summit; PLV, Posterior lateral vein; LV, lateral vein; MA, mitral annulus; TA, tricuspid annulus; PSCs; pulmonary sinus cusp; ASC; aortic sinus cusp. RAO = right anterior oblique; LAO = left anterior oblique.

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  Figure 3. The QRS morphology of idiopathic ventricular arrhythmias (IVAs) originating from the CVS. pAIV, the proximal portion of the anterior interventricular vein; mAIV, the mid portion of the anterior interventricular vein; pMCV, the proximal portion of the middle cardiac vein; pPLV, the proximal portion of the posterior lateral vein; mPLV, the mid portion of the posterior lateral vein.

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  Figure 4. The QRS morphology of IVAs originating from the endocardial mitral annulus(endo-MA).

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  Figure 5. The ROC curve for diagnosing IVAs originating from the CVS. Pdw, pseudo delta wave; IDT, intrinsicoid deflection time; MDI, the maximum deflection index; AUC, Area Under Curve.

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  Figure 6. Example of ablation of IVAs originating from the Summit-CV. Epicardial mapping and ablation were performed in a 66 year-old woman with clinical IVAs. No structural heart disease was evident on echocardiography. Preoperative surface ECG ((A1), activation mapping (A2) and pace mapping (A3) demonstrated rS wave on lead I, tall R wave on leads II, III, and aVF, and R wave in lead V1–V6. The local ventricular activation time recorded at Summit-CV preceded the onset of the QRS complex by 35 ms (A2) and pacing this site led to a 98.8% concordance with the QRS complex of IVA (A4). Activation mapping (A2) shows the intracavity bipolar electrogram (ABL-d) recorded from systolic high-amplitude potential to presystolic high-amplitude potential once mapping at ideal target site. (B1,B2) Electroanatomical map of the aortic sinus of Valsalva, the summit of the left ventricle, and Summit-CV. (C1,C2) show the fluoroscopic position of the ablation catheter site and coronary angiography (CAG). The middle segment of the left anterior descent branch (LAD) is located about 5.16 mm from the proximal edge of the ablation electrode at the ideal ablation site (note that the distal electrode of the…