Ventricular Arrhythmias Linked to the Left Ventricular Summit Communicating Veins

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 11, No. 1Ventricular Arrhythmias Linked to the Left Ventricular Summit Communicating Veins Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBVentricular Arrhythmias Linked to the Left Ventricular Summit Communicating VeinsA New Mapping Approach for an Old Ablation Problem Daniele Muser, MD and Pasquale Santangeli, MD, PhD Daniele MuserDaniele Muser From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia. and Pasquale SantangeliPasquale Santangeli From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia. Originally published11 Jan 2018https://doi.org/10.1161/CIRCEP.117.006105Circulation: Arrhythmia and Electrophysiology. 2018;11:e006105See Article by Komatsu et alThe left ventricular summit (LVS) is the most superior portion of the epicardial LV outflow tract and is a common site of origin of idiopathic ventricular arrhythmias (VAs).1,2 The LVS is anatomically bounded septally by the bifurcation between the left anterior descending and the left circumflex coronary arteries, and transected laterally by the great cardiac vein at the junction with the anterior interventricular vein.3 A proper knowledge of the specific anatomic boundaries within the LVS has substantial clinical relevance with respect to the mapping and ablation approach. The junction between the great cardiac vein and the anterior interventricular vein separates the LVS into an accessible region, lateral to the venous junction and remote from the bifurcation of the left main coronary artery and the epicardial fat around the atrioventricular groove, and an inaccessible region septal to the venous junction and in close proximity to the proximal left coronary arteries and epicardial fat. Although VAs arising from the accessible LVS are rarely problematic and usually can be mapped and ablated from the distal coronary venous system or directly via a percutaneous pericardial approach,2,4 VAs from the inaccessible region represent a major clinical challenge.Direct epicardial mapping of the inaccessible LVS via a percutaneous epicardial access is limited mainly by the presence of a thick layer of epicardial fat which effectively insulates the underlying epicardium and prevents adequate electrogram recordings; in many cases catheter manipulation is challenging because of the anatomic proximity of the left atrial appendage. Furthermore, direct epicardial radiofrequency application to the inaccessible LVS is rarely possible because of the close proximity to the proximal left coronary system and, occasionally, to the left phrenic nerve. When ablation is possible it may be ineffective because of poor energy penetration through fat.2,5To overcome these challenges, an ablation approach targeting sites anatomically adjacent to the inaccessible LVS has been proposed by several authors, with success rates ranging from 25% to ≈75%.6–8 The choice of the optimal ablation site among different adjacent regions is usually based on a multiparametric assessment that takes into consideration activation mapping results (second best site), pacemapping data and the anatomic distance between the adjacent sites. When standard ablation approaches are not effective, alternative ablation strategies have been proposed including use of simultaneous unipolar radiofrequency ablation,9 bipolar radiofrequency ablation,10 alcohol arterial/venous ablation,11 or surgical epicardial ablation with direct visualization of the coronary vessels and dissection of the epicardial fat.5In this context, Komatsu et al12 describe a new technique to obtain direct recordings from the inaccessible LVS via a 2F multipolar microcatheter introduced into the summit communicating veins (CV) which runs between the aortic and the pulmonary annulus. The study comes from a very experienced group of investigators, and describes a novel mapping technique which will have important clinical implications for mapping and ablation of LVS-VAs. Owing to the specific design of the mapping catheters used in this study, the authors were able to obtain a detailed definition of the anatomy of the distal coronary sinus. In particular, a 6F decapolar catheter equipped with an inner lumen was positioned within the distal coronary sinus and contrast was injected through the catheter to delineate the takeoff of the summit-CV and allow advancement of a 2F microcatheter via the lumen of the decapolar catheter. Notably, the summit-CV could be identified and mapped in all patients: in this respect, it is unclear how much supplemental effort in terms of both procedural and fluoroscopy time was required to instrument the summit-CV and in how easy it was to conclusively distinguish the summit-CV from other branches of the distal great cardiac vein/anterior interventricular vein.Out of a total of 31 consecutive patients with idiopathic outflow tract VAs who underwent LVS mapping with the 2F microcatheter, the summit-CV was identified as the site of origin of the VA in 14 (45%) cases. This was based on detailed activation mapping which included interrogation of the endocardial outflow tracts, coronary cusps, and distal coronary venous system coupled with best pacemap (≥11/12 leads). The apparently high prevalence of summit-CV reported in this study very likely reflects selection bias, as also pointed out by the authors12; in fact, the study population was extracted from a larger group of 229 patients undergoing catheter ablation of idiopathic VAs at the same institution, and the decision to map the summit-CV was discretional. The ECG characteristics of summit-CV arrhythmias reflected the origin from the posterior and septal aspect of the LVS, with a nonspecific R/S pattern in lead V1 without pattern break in V1 through V3—which instead would have pointed to the anteroseptal LVS close to the anterior interventricular groove13—and a slightly deeper Q wave amplitude in aVL compared with aVr suggesting origin slightly leftward to the torso midline. Notably, in none of the summit-CV cases it was possible to target the arrhythmia with direct ablation at the site of earliest activation mainly because the vein was too small to accommodate a mapping/ablation catheter, and an anatomic approach with application of radiofrequency energy at anatomically adjacent sites was used instead. The inability to directly ablate the earliest site within the LVS is a recurrent theme and, in our view, it remains the biggest challenge when tackling these arrhythmias, as also documented in prior reports (Table).Table. Summary of Studies Evaluating Catheter Ablation of Ventricular Arrhythmias Linked to the Distal Coronary Venous SystemStudy Reference No.No. of PatientsSite of Earliest Activation Recorded (No. of Patients)Earliest Activation Time (Pre-QRS), msSite of Ablation (No. of Patients)Reasons for Not Performing Ablation at the Earliest Activation Site Within CVS (No. of Patients)Acute Procedural Success, %Complications (No. of Patients)Follow-Up, moLong-Term Success (% of Patients With Acute Procedural Success)Daniels et al1412GCV (2)AIV-GCV junction (3)Proximal AIV (4)MCV (3)47±7Inside CVS at earliest activation site (6)Percutaneous epicardial (6)Inability to advance the ablation catheter to the site of earliest activation (6)92%Pericarditis with mild effusion related to percutaneous epicardial ablation (1)NANAObel et al155Distal GCV (5)NAInside CVS at earliest activation site (5)…100%NoneMean 25100%Baman et al1627Distal GCV (26)MCV (1)29±8Inside CVS at earliest activation site (20)Inside CVS proximal to the earliest activation site (5)Percutaneous epicardial (2)Proximity to coronary arteries (1)Inability to advance the ablation catheter to the site of earliest activation (4)Inadequate power delivery (1)Proximity to phrenic nerve (1)74%NoneMedian 1390%Yamada et al1714Distal GCV/AIV (14)37±10Inside CVS at earliest activation site (9)Not performed (5)Inability to advance the ablation catheter to the site of earliest activation/ inadequate power delivery (5)64%NA1264%Yamada et al125Distal GCV/AIV (25)Median 32Inside CVS at earliest activation site (20)Percutaneous epicardial (5)Inability to advance the ablation catheter to the site of earliest activation (1)Inadequate power delivery (4)Failed ablation at the earliest activation site (1)65%NoneMedian 12100%Yokokawa et al1833Distal GCV/AIV (32)MCV (1)30±6Inside CVS at earliest activation site (10)Inside CVS proximal to the earliest activation site (4)Inside CVS proximal to the earliest activation site/ LV endocardium/aortic cusps region (8)LV endocardium / aortic cusps region (4)Percutaneous epicardial (4)Not performed (3)Inability to advance the ablation catheter to the site of earliest activation (5)Proximity to coronary arteries/phrenic nerve (3)Inadequate power delivery (3)67%None12 to 4891%Jaureguiet Abularach et al616Distal GCV/AIV12 to 75Left sinus of Valsalva (5)Adjacent LV endocardium (2)Both of the above (2)Inability to advance the ablation catheter to the site of earliest activation/proximity to coronary arteries/inadequate power delivery56%Pericardial effusion (1)Narrowing of obtuse marginal coronary artery branch (1)NANASteven et al1914Distal GCV39±9Inside CVS at earliest activation site (7)Proximity to coronary arteries (6)Inadequate power delivery (1)43%NANA83%Li et al2012Distal GCV (4)Extended tributary of GCV distal to the origin of AIV (3)Proximal AIV (5)37±3Inside CVS at earliest activation site (12)…100%NoneMedian 1783%Frankel et al212AIV25Septal RVOT (2)Close proximity to coronary arteries (2)100%NoneMedian 24100%Li et al2230Distal GCV (anterior-lateral mitral annulus) (8)Distal GCV (AIV opening proximal end) (6)Extended tributary of GCV distal to the origin of AIV (6)Proximal AIV (10)36±6Inside CVS at earliest activation site (30)…100%NA18±1393%Nagashima et al2330GCV (30)37±8Inside CVS at earliest activation site (15)Adjacent sites outside CVS (19)Percutaneous epicardial (2)Open chest surgical ablation (3)Proximity to coronary arteries (14)Inability to advance the ablation catheter to the site of earliest activation (3)Failed ablation at the earliest activation site (7)53%Coronary artery occlusion requiring stenting of A marginal branch of the circumflex artery (2)GCV perforation (1)Median 3100%Mountantonakis et al447Distal GCV (25)AIV (19)MCV (3)39±18Inside CVS at earliest activation site (18)Inside CVS proximal to the earliest activation site (14)Adjacent sites outside CVS (15)Proximity to coronary arteries (21)Inability to advance the ablation catheter to the site of earliest activation (4)Inadequate power delivery (2)Operator choice (2)94% with ablation at the earliest CVS site55% with ablation at adjacent CVS or non-CVS sitesFemoral arteryPseudoaneurysm (1)Pericardial effusion due to CS perforation (1)Stenosis of the proximal circumflex coronary artery (1)31±2176%Santangeli et al223Epicardial LVS (21)AIV (2)31±10Percutaneous epicardial (14)Close proximity to coronary arteries (9)22%Pericardial effusion because of perforation of the GCV (1)Median 3660%Yamada et al924Distal GCV<−20 (22)>−20 (2)Inside CVS at earliest activation site (24)AMC (9)Simultaneous unipolar RF ablation from AMC and GCV (3)Failed ablation at the earliest activation site (9)100%None6100%Lin et al2416GCV/AIV30±16 msInside CVS at earliest activation site (16)…100%NoneMedian 1688%Yamada et al723GCV (16)Communicating branch of the GCV (7)<−20Inside CVS at earliest activation site (23)Inside CVS proximal to the earliest activation site (1)AMC (1)LCC (1)Inadequate power delivery (1)Failed ablation at the earliest activation site (2)100%NoneMedian 55100%Yamada et al2540Distal GCV<−20 (38)>−20 (2)Inside CVS at earliest activation site (40)AMC (12)Simultaneous unipolar RF ablation from AMC and GCV (3)Failed ablation at the earliest activation site (12)100%NoneMedian 51NAAIV indicates anterior interventricular vein; AMC, aorto-mitral continuity; CS, coronary sinus; CVS, coronary venous system; GCV, great cardiac vein; LCC, left coronary cusp; MCV, middle cardiac vein; NA, not available; RF, radiofrequency; and RVOT, right ventricular outflow tract.Acute success with complete elimination of the VAs was observed only in 8 (57%) cases. As expected, the anatomically adjacent sites where ablation was attempted were characterized by worse activation times and pacemaps,8 although the successful cases had a shorter activation interval between the summit-CV and the selected adjacent site, and likely represented the second best site identified at activation mapping. As such, similar outcomes may have been obtained by a more pragmatic and less elegant ablation approach targeting the earliest site reachable with a standard ablation catheter, even without direct mapping of the site of origin within the summit-CV.Interestingly, there appeared to be no other clinical, ECG or procedural features associated with higher likelihood of successful ablation from an adjacent site. In this regard, it would have been of value to report information on the time to VA suppression as well as the regional wall thickness between the summit-CV and the adjacent site selected for ablation. The latter could be indexed as distance between the mapping catheter at the summit-CV and the ablation site on the 3-dimensional mapping system and may have provided important clues on why some patients responded better to ablation from an adjacent vantage point, as prior studies have suggested that there may be a critical distance below which an anatomically-based ablation approach for LVS arrhythmias is more likely to be successful.6In conclusion, Komatsu et al12 should be congratulated for describing a new approach that helps determine the true site of origin of VAs within a region of the LVS that is otherwise inaccessible for mapping with a standard ablation catheter. The results of this study support the need for detailed mapping the summit-CV when tackling VAs from the inaccessible LVS. Further research should be focused on better ablation tools and approaches to enhance success from anatomically adjacent sites.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org.Correspondence to: Pasquale Santangeli, MD, PhD, Cardiovascular Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion–Cardiology, 3400 Spruce St, Philadelphia, PA 19104. E-mail [email protected]References1. Yamada T, McElderry HT, Doppalapudi H, Okada T, Murakami Y, Yoshida Y, Yoshida N, Inden Y, Murohara T, Plumb VJ, Kay GN. Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation.Circ Arrhythm Electrophysiol. 2010; 3:616–623. doi: 10.1161/CIRCEP.110.939744.LinkGoogle Scholar2. 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