Approach selection of radiofrequency catheter ablation for ventricular arrhythmias originating from the left ventricular summit: potential relevance of Pseudo Delta wave, Intrinsicoid deflection time, maximal deflection index

Figures

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  Fig. 1. Distribution of PdW time and precordial IDT and MDI values of VAs from transaortic group, transseptal group and trans-DGCV group. PdW > 53 ms, IDT > 74 ms, MDI > 0.45 suggested ablation by the trans-DGCV approach. Receiver Operating characterisitcs (ROC) curve showed that PdW, IDT, MDI of VAs had a good ability to differentiate trans-DGCV approach and non-trans-DGCV approach (transaortic and transseptal approach) with area under curve (AUC) of 0.9098, 0.8988, 0.8806 respectively

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  Fig. 2. Example of intervals measured in VAs from transaortic group, transseptal group and trans-DGCV group. a.Transaortic group b.Transseptal group c. Trans-DGCV group

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  Fig. 3. PVCs originating from the left ventricular endocardial summit were ablated by a retrograde transaortic approach. A. PVCs showed the morphology of complete right bundle branch block in precordial leads, with monophasic R wave in leads II, III, aVF, QS in leads aVL and aVR, and rS in lead I. Activation mapping showed that during the sinus rhythm,the earliest ventricular activation of PVCs was recorded in left ventricular endocardial summit and preceded the QRS onset by 42 ms; pacing the site of the earliest ventricular activation resulted in a perfect match to spontaneous PVCs. B. Fluoroscopy of target site. C. Three-dimension mapping of target site. The irrigated-tip ablation catheter was located in the left ventricular endocardial summit, and RF current was delivered with a target temperature of 43 °C and maximum power output of 35 W, flow rate 17 ml/min. The PVCs disappeared after energy application for 3 s, and additional RF current then was applied for another 60s. There was no recurrence during 3.5 years follow-up. Annotation: LAO = left anterior oblique; RAO = Right anterior oblique; ABL = ablation catheter

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  Fig. 4. PVCs originating from left ventricular epicardial summit were ablated by an antegrade DCGV approach. a. PVCs showed the morphology of complete right bundle branch block, with precordial transition zone before V1, monophasic R in leads II, III, aVF and V3-6, RIII > RII, QS in leads aVL and aVR, QSaVL > QSaVR, rS in lead I. b. The irrigated-tip ablation catheter was delivered to the DCGV via the coronary sinus for mapping and ablation, the earliest ventricular activation of PVCs were recorded in the left ventricular epicardial summit preceding the QRS wave onset by 37 ms. c. Pacing the site of the earliest ventricular activation yielded a perfect match to spontaneous PVCs. d. Fluoroscopy of target site. e. Three-dimension mapping of target site. The ablation catheter was located in the left ventricular epicardial summit, and irrigated RF current was delivered with a target temperature of 43 °C, maximum power output of 25 W, and flow rate of 30 ml/min. The PVCs disappeared after energy delivery for 6 s; additional RF current then was applied for another 60s. There was no recurrence during 0.5 years follow-up

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  Fig. 5. PVCs originating from the left ventricular summit were ablated by antegrade transseptal approach. a. PVCs showed the morphology of complete right bundle branch block in precordial leads with precordial transition zone before lead V1, monophasic R in leads II, III, aVF and V3-6, RIII > RII, QS in leads aVL and aVR, QSaVL > QSaVR, rS in lead I. A retrograde transaortic approach was firstly attempted, but failed. The irrigated-tip ablation catheter was then delivered to DCGV via coronary sinus for mapping and ablation. During sinus rhythm, the earliest ventricular activation of PVCs was recorded within DGCV of the left ventricular epicardial summit and preceded QRS wave onset by 32 ms. b. Pacing the site of the earliest ventricular activation within DGCV resulted in a perfect match to spontaneous PVCs in 12 leads. c. The ablation catheter was located in DCGV, and coronary angiography showed that the distance between the tip of ablation catheter and left coronary artery was more than 5 mm. Irrigated RF current was delivered with a target temperature of 43 °C, maximum power output of 25 W, and flow rate of 30 ml/min. After several times of ineffective RFCA in this area, the trans-DGCV…