Right ventricular outflow tract ablation associated with anomalous origin of coronary artery: A “double-edged sword”

Figures

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  Figure 1. Septal RVOT-NSVT. QRS complexes with LBBB morphology, inferior axis, late transition (V4), V2 transition ratio 0.35, V2S/V3R 3.72. The absence of notching in inferior leads suggested an origin from the septal aspect of the RVOT. LBBB = left bundle branch block; NSVT = non-sustained ventricular tachycardia; RVOT = right ventricle outflow tract.

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  Figure 2. A: Coronary angiography demonstrated the common origin of the LMCA (blue arrow) and the RCA (white arrow) from the right coronary sinus. B: Contrasted chest CT. The prepulmonary course of the LMCA is seen (green arrow). C: CT coronary angiogram. Coronal view of the heart showing the anomalous origin of the LMCA (green arrow) from the right coronary sinus. The RCA (red arrow) also originates from the same coronary sinus. The 58° birth angle, the oval morphology of the ostium and the absence of an intramural course can be seen. D: Cardiac volumetric reconstruction. Demonstrates the absence of interarterial course (between the aorta and pulmonary artery) of the LMCA. E: Myocardial perfusion test negative for ischemia. F: Cardiac magnetic resonance imaging. Absence of late gadolinium enhancement in 4-, 2- , 3- and 5-chamber views. CT = computed tomography; LMCA = left main coronary artery; RCA = right coronary artery.

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  Figure 3. A: VT induction with morphology identical to that objectified in 2018. B: Activation map showing the earliest activation at the posteroseptal aspect of the RVOT (25 ms pre-QRS with a negative deflection [QS morphology] in the unipolar electrogram). B, C: 3D electroanatomic map integrated to the CT coronary angiogram. Notice the relationship between the ablation catheter and the coronary trajectory. D: Ablation points (30W, ablation index of 450) with subsequent disappearance of ventricular extrasystoles. 3D = 3-dimensional; CT = computed tomography; RVOT = right ventricle outflow tract; VT = ventricular tachycardia.