Unique features of epicardial ventricular arrhythmias/premature ventricular complexes ablated from coronary venous system in veteran population

Figures

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  Fig. 1. Corornary sinus venogram done in a case where site of earliest activation was in middle cardiac vein. 2A: Shows coronary sinus venogram with decapolar bidirectional catheter inside the coronary sinus and SR0 sheath used for venogram. 2B: Shows ablation catheter (4) in middle cardiac vein 2C: Shows mechanical pressure resulted in suppression of the PVCs. In this case site with earliest activation and successful ablation was in the middle cardiac vein. 1: Decapolar bidirectional coronary sinus catheter, 2: Quadripolar deflectable catheter positioned at His, 3: Quadripolar deflectable catheter positioned at base of right ventricle. CS: Coronary sinus, MCV: middle cardiac vein, Sheath: SR0 sheath used for venogram.

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  Fig. 2. Intracardiac electrograms in a case with site of earliest activation in distal Coronary venous system. The near field earliest electrograms was 24 ms earlier than the PVC QRS onset. The unipolar electrograms shows a QS pattern and starts earlier than bipolar electrograms.

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  Fig. 3. Pacing from the site with earliest activation has been superimposed on the clinical PVC. It showed more than 95% pacematch.

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  Fig. 4. Coronary arteriogram done in subject 134. Note the relative proximity of the ablation catheter (marked 1) to the left circumflex coronary artery (marked 3) in both left (LAO) and right (RAO) anterior oblique views; numbers in caption refer to viewing angles in degrees. 1: Ablation catheter, 2: Decapolar bidirectional coronary sinus catheter, 3: Left circumflex coronary artery, 4: Left anterior descending coronary artery.

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  Fig. 5. CARTO map showing ablation of a PVC in the coronary venous system. CS: Coronary sinus LV: Left ventricle RCC: Right coronary cusp (aortic sinus of Valsalva) The catheter with green tip in CS is the ablation catheter. The other catheter in CS is the decapolar bidirectional catheter.

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  Fig. 6. A: 12 Lead Electrocardiogram showing premature ventricular complex with right bundle branch block type, right inferior axis morphology. The successful ablation site was in the distal coronary venous sysetm. B: Electrocardiogram showing premature ventricular complex with right bundle branch block type, right superior axis morphology. The successful ablation site was in the middle cardiac vein. C: PVC from middle cardiac vein in cardiac electrophysiology laboratory with measurements. PVC duration of 185 ms, QRS onset to peak of Lead V2 = 101 ms, Pseudo-delta wave duration = 50 ms, RS duration of 138 ms, precordial maximum deflection index (MDI) = 78 ms/185 ms = 0.42. A majority of the measurements suggest an epicardial origin of the PVC.