Ventricular premature complexes successfully ablated from the non-coronary cusp: a case report

Figures

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  Figure 1. (A) Twelve-lead electrocardiography of the ventricular premature complexes. Clinical ventricular premature complexes had an inferior axis and left bundle branch block morphology with a precordial transition between V4 and V5. The QRS morphology has the left bundle ranch block, left axis, and upright R waves in Lead I with the QRS duration of 128 ms and III/II ratio of 0.62. (B) Pace mapping at the right ventricular outflow tract septum. No good pace mapping was obtained at the right ventricular outflow tract (8 of 12 leads were identical to the clinical ventricular premature complexes). (C) Pace mapping at the right coronary cusp. Pacing at the earliest activation site was similar to target ventricular premature complexes, but a perfect pace map was not obtained (10 of 12 leads were identical to the clinical ventricular premature complexes). RCC, right coronary cusp; RVOT, right ventricular outflow tract; VPCs, ventricular premature complexes.

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  Figure 2. Our protocol for ventricular premature complex ablation. We always map the right ventricular outflow tract first to minimize the risk of complications, even if the electrocardiography morphology is compatible with that of the left ventricular outflow tract. If no good pace mapping or earlier potential preceding to surface electrocardiography at the right ventricular outflow tract is obtained, then we map the aortic cusps and the left ventricular outflow tract. A 20-polar electrode monorail catheter is routinely positioned into the anterior interventricular vein for monitoring the great cardiac vein and anterior interventricular vein. Only after unsuccessful left ventricle endocardial ventricular premature complex ablation, left ventricle epicardial mapping may thus be considered. AIV, anterior interventricular vein; ECG, electrocardiograms; GCV, great cardiac vein; LV, left ventricle; LVOT, left ventricular outflow tract; RVOT, right ventricular outflow tract; VPCs, ventricular premature complexes.

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  Figure 3. (A) Angiography of the left ventricular outflow tract in the right anterior oblique view. The 20-polar electrode catheter was positioned percutaneously through the coronary sinus into interventricular vein. (B) Fluoroscopic image of the earliest activation site of recurrent ventricular premature complexes in the left ventricular outflow tract in the right anterior oblique view. The ablation catheter was located at the right coronary cusp. The diagnostic catheter was placed in the coronary sinus-interventricular vein. (C) Fluoroscopic image of the earliest activation site of recurrent ventricular premature complexes in the right ventricular outflow tract in the right anterior oblique view. The ablation catheter was in the His region. (D) Fluoroscopic image of the successful ablation site in the right anterior oblique view. Energy application to the non-coronary cusp successfully eliminated the ventricular premature complexes. AIV, anterior interventricular vein; CS, coronary sinus; LVOT, left ventricular outflow tract; NCC, non-coronary cusp; RCC, right coronary cusp; RV, right ventricular; RVOT, right ventricular outflow tract; TA, tricuspid annulus; VPCs, ventricular premature…

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  Figure 4. (A) CARTOSOUND and intracardiac echocardiography images of the aortic cusp. (B) Activation map of ventricular premature complexes. The geometry of the aortic cusp was reconstructed by CARTOSOUND. Three-dimensional mapping using CARTO 3 revealed the earliest activation at the right coronary cusp. ICE, intracardiac echocardiography; LV, left ventricle; NCC, non-coronary cusp; RCC, right coronary cusp; VPCs, ventricular premature complexes.

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  Figure 5. (A) Electrograms of target ventricular premature complexes were obtained by the ablation catheter. The local potential at the right coronary cusp preceded surface electrocardiography by 28 ms. Electrograms of the coronary sinus (coronary sinus; 19–20 proximal and 1–2 distal) are shown from top to bottom at a paper speed of 100 mm/s. (B) Electrograms of the earliest activation site of the recurrent ventricular premature complexes in the right ventricular outflow tract. The pre-potential preceded surface electrocardiography by 34 ms during ventricular premature complexes, and a clear His potential was recorded during sinus rhythm. (C) The electrograms of the recurrent ventricular premature complexes were obtained at the non-coronary cusp. The local potential at the non-coronary cusp preceded the surface electrocardiography by 22 ms; however, that was not the earliest. Far-field His potentials were recorded at the non-coronary cusp during sinus rhythm. CS, coronary sinus; ECG, electrocardiograms; NCC, non-coronary cusp; RCC, right coronary cusp; RVOT, right ventricular outflow tract; VPCs, ventricular premature complexes.

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