Catheter Ablation of Ventricular Arrhythmias Originating From the Region of DGCV-AIV via a Swartz Sheath Support Approach

Figures

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  Figure 1. Different approaches for ablation catheter reaching target sites in DGCV. (A) Manipulation of the ablation catheter in GCV by non-Swartz sheath support (NS) approach. (A1,A2) The tip of the catheter was delivered to DGCV from the ostium of the coronary sinus directly. (B) Manipulation of the ablation catheter in GCV by Swartz sheath support (SS) approach. (B1,B2) The tip of the catheter was delivered to summit-CV with support from Swartz sheath in the GCV. (C) Super smooth guidewire and left coronary angiographic catheter-guided deep engagement of Swartz sheath in GCV. (C1) Due to the blockage of the Vieussens valve (shown by coronary venography), even with the support of Swartz sheath, the catheter tip could not reach the middle part of GCV. (C2) The hydrophilic coated guide wire and Judkin's 4-left coronary catheter were delivered through a Swartz sheath and passed the Vieussens valve and reached the DGCV. (C3,C4) The guided guide wire and coronary catheter, the Swartz sheath was advanced alternately and passed the Vieussens valve, then the guidewire and Jukin's catheter was exchanged with ablation catheter to perform mapping and ablation in DGCV. (D) Schema of NS approach for…

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  Figure 2. Anatomy of DGCV-AIV and anatomic obstacles preventing catheterization in GCV. (A,B) Anatomy of DGCV-AIV. (C,D) Anatomic obstacles preventing catheterization in GCV. (D) Angle formed between DGCV and AIV, and an angle <83° prevented the ablation catheter from advancing from DGCV into AIV. (E) Different morphology of GCV, and Width/Hight>0.69 more favored the application of the SS approach. (E) Venous valve (Vieussens valve) in GCV. (F) Thin lumen of summit-CV. DGCV, distal great cardiac vein; AIV, anterior interventricular vein; summit-CV, communicating vein in the left ventricular summit. RVOT, right ventricular outflow tract; LVOT, left ventricular outflow tract; TA, tricuspid annulus; MA, mitral annulus; CS, coronary sinus.

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  Figure 3. Flowchart of mapping and ablation procedure in this study.

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  Figure 4. An example of successful ablation of premature ventricular complex (PVC) originating from Summit-CV by SS approach. (A) Twelve-lead ECG 3 morphology of the clinical PVC. The PVC showed R wave in II, III, aVF, V4-V6, rS morphology in lead V1, the precordial transition zone of PVC was earlier than sinus beat. (B) By NS approach, the irrigated catheter could reach the distal portion of GCV. SS approach was then applied in this patient. By SS approach, the irrigated catheter reached the target site in summit-CV. The local ventricular activation time recorded at the summit-CV preceded the onset of the QRS complex by 52 ms, and a perfect pace-match was achieved by pacing at summit-CV. (C1–C3) Fluoroscopic view of the target site in summit-CV. (D1,D2) Three-dimension view of target site in Summit-CV. (E) Radiofrequency energy delivered on target site for 5 seconds led to an acute disappearance of target PVCs.