A case of accessory pathway mapped with ultra‐high‐resolution mapping led to a coronary sinus diverticulum

Figures

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  FIGURE 1. The 12‐lead electrocardiogram during sinus rhythm. Delta wave polarity was positive in lead I and negative in leads II and aVF, and the amplitudes of the R wave was greater than that of the S wave in lead V1

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  FIGURE 2. A, Intracardiac electrocardiogram (ECG) during sinus rhythm. B, Intracardiac ECG during right ventricular apex pacing. An accessory conduction pathway was detected at coronary sinus 7‐8 (the posterior mitral annulus). C, Intracardiac ECG during tachycardia. The site of the earliest atrial activation during tachycardia matched the sequence during right ventricular apex pacing. Therefore, her tachycardia was concluded to be orthodromic atrioventricular reciprocating tachycardia, and the accessory pathway in the posterior mitral annulus was part of its circuit

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  FIGURE 3. A, Ultra‐high‐resolution map of the atrial wall next to the posterior mitral annulus during right ventricular pacing. The marker in the figure shows propagation from the ventricle to the atrium in the posterior mitral annulus near the ostium of the coronary sinus. B, Ultra‐high‐resolution map of the atrial wall next to the posterior mitral annulus during sinus rhythm. The marker in the figure shows propagation from the atrium to the ventricle. The yellow tag indicates the site of the earliest atrial activation during right ventricular apex pacing

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  FIGURE 4. Intracardiac ECG of the site of ablation of the atrial wall next to the posterior mitral annulus. When the ablation catheter was placed at the site of the earliest activation in the atrial wall next to the posterior mitral annulus, detected by the Rhythmia system, the local potential of the catheter detected a preceding A wave during right ventricular apex pacing

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  FIGURE 5. Coronary sinus (CS) angiography. CS angiography identified a diverticulum with its neck extending downward at the site of CS 7‐8 (about 1 cm from the CS ostium)

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  FIGURE 6. A, Intracardiac echocardiogram (ECG) during ablation of the neck of a CS diverticulum from within the CS. When an ablation catheter was placed at the neck of the diverticulum, an A wave preceding the wave detected at the endocardial site of ablation was observed during right ventricular apex pacing. B, Ablation at the neck of the CS diverticulum. The accessory pathway was blocked in about 6 seconds after the ablation of this site

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  FIGURE 7. The ablation sites in this study. The yellow tag indicates the site of the earliest atrial activation and the site of the first endocardial ablation during right ventricular apex pacing, as shown by the Rhythmia system. The red tag indicates the site of additional ablation in the endocardium. The blue tag indicates the site of ablation in the neck of the diverticulum (successful ablation of the accessory pathway). The pink tag indicates the site of additional ablation from within the CS