Role of intracardiac echocardiography for guiding ablation of tricuspid valve arrhythmias

Figures

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  Figure 1. A, B: Anatomy of the tricuspid valve (TV). (Reproduced from Dr K. Shivkumar with permission. Copyright UCLA Cardiac Arrhythmia Center, McAlpine Collection.) C, D: Computed tomography image of the heart showing the right ventricle inflow and outflow regions to demonstrate the position of the ablation catheter from a femoral approach. C: Ablation of tricuspid annular ventricular arrhythmias from an inferior approach limited by the ablation catheter being hindered by the anterior TV leaflet. D: Infratricuspid approach using a steerable sheath and a reversed S-curve allows to overcome this obstacle and reach the subvalvular tissue. AL = anterior leaflet; Ao = aorta; APM = anterior papillary muscle; CS = crista supraventricularis; PL = posterior leaflet; PPM = posterior papillary muscle; PV = pulmonic valve; SL = septal leaflet; SPM = septal papillary muscle.

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  Figure 2. Ablation of premature ventricular contraction (PVC) mapped to the top of the tricuspid valve (TV). A: Image shows failure to eliminate the PVCs with the standard approach, guided by fluoroscopy. Sites recording His potentials are marked in yellow. B: Image shows incorporation of intracardiac echocardiography for real-time assessment of TV annulus/leaflets and catheter–tissue contact. The same site of earliest activation is approached with a double loop on the ablation catheter, avoiding the anterior leaflet and resulting in a perpendicular vector of contact. PVCs were quickly eliminated. RA = right atrium; RV = right ventricle; TV = tricuspid valve.

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  Figure 3. A: Activation map of the right ventricle during atrial pacing showing earliest activation at 9 o’clock on the tricuspid annulus. B: Intracardiac echocardiography imaging of the lateral tricuspid valve (TV), showing a small pouch or recess (red arrow) immediately below the TV. C: Positioning of the catheter inside the pouch, demonstrated by the green mark. D: Left anterior oblique and right anterior oblique views showing the position of the catheter at the successful ablation site. E: Elimination of accessory pathway conduction during ablation.

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  Supplemental Figure 1. Patient 2. A. Twelve-lead ECG of the clinical PVC. B. Electrogram at site of earliest activation. C. Activation map of the RV showing earliest site in red and His potentials in yellow. D. ICE view obtained with the ICE catheter in the RA. E. Integration of CARTO map and RAO fluoroscopic view, showing the position of the catheter at the time of successful ablation. F. PVC elimination.

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  Supplemental Figure 2. Patient 3. A. Twelve-lead ECG of the clinical PVC. B. Standard approach limited by the presence of the TV leaflets. C. “Reversed S” technique with better reach to the subvalvular tissue. D. Integration of CARTO map and RAO fluoroscopic view, showing the position of the catheter at the time of successful ablation. E. PVC elimination.

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  Supplemental Figure 3. Patient 5. A. Baseline ECG showing ventricular preexcitation compatible with right lateral accessory pathway. B, D. Initial failed ablation attempt (ICE visualization and fluoroscopic LAO view). ICE shows the presence of the TV leaflet between the catheter tip and the underlying ventricular myocardium. C, E. By advancing the sheath further into the RV and placing a closed loop on the ablation catheter, the tip is positioned below the TV leaflet, in direct contact with the annulus. Ablation in this spot resulted in successful accessory pathway elimination.