Optimizing Accessory Pathway Ablation in Coronary Sinus Diverticulum Using Internal Jugular Route With 3D-Mapping

Figure 1. Baseline Electrocardiogram Baseline electrocardiogram showing sinus rhythm with a negative delta wave in leads II, III, and aVF.

Figure 2. Coronary Sinus (CS) Venography Image CS venography image showing a large diverticulum in the proximal part of the floor of the CS. Blue arrows mark the boundary of the CS diverticulum. CS = coronary sinus.

Figure 3. 3D Electroanatomic Mapping 3D electroanatomic mapping using the CARTO 3 system showing the anatomy and 3D geometry of the CS diverticulum in left anterior oblique and posteroanterior views. The earliest local activation time during mapping in sinus rhythm is shown inside the body of the CS diverticulum. Irrigated radiofrequency ablation was turned on at this site, with loss of ventricular pre-excitation and separation of atrioventricular signals noted at 1.45 seconds. The red arrow denotes the anatomy of the CS diverticulum. The yellow arrow denotes the anatomy of the main body of the CS (truncated). The blue arrow shows the course of ablation catheter via the internal jugular vein approach. 3D = 3-dimensional; CS = coronary sinus.

Figure 4. Postablation Electrocardiogram Postablation electrocardiogram showing sinus rhythm with no delta wave. T-wave inversion suggestive of cardiac memory T waves after radiofrequency ablation.

Visual Summary. Case Overview Case overview demonstrating successful posteroseptal accessory pathway ablation within a CS diverticulum using the internal jugular route and 3D mapping after previous failed ablation attempts. 3D = 3-dimensional; CS = coronary sinus; ECG = electrocardiogram; RF = radiofrequency; WPW = Wolff-Parkinson-White.