Surgical Mapping and Ablation in the Left Ventricular Summit Guided by Presurgery Pericardial Mapping

Figures

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  Figure 1:. Twelve-lead ECG shows sinus rhythm with ventricular bigeminy.

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  Figure 2:. A: Ventricular activation (dABL) precedes the onset of surface QRS by 35 ms. pABL and dABL denote the proximal and distal bipolar electrode pairs of the mapping catheter, respectively. B: Pacing at this location showed a 10/12 ECG QRS match. C: Coronary angiogram in the left anterior oblique caudal projection. Mapping catheter was placed in the pericardial space through a deflectable sheath. The earliest activation site is located just medial (septal) to the proximal LAD artery. RV: quadripolar catheter in the right ventricular apex; CS: decapolar catheter in the coronary sinus.

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  Figure 3:. The epicardial fat over the LV anterobasal area was dissected and a small retractor was placed in the epicardial fat to expose the underlying myocardial surface. A mapping catheter was located just medial (septal) to the proximal LAD artery.

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  Figure 4:. A: On the left, ventricular activation (dABL) precedes the onset of surface QRS by 60 ms. pABL and dABL denote the proximal and distal bipolar electrode pairs of the mapping catheter, respectively. In the middle, an abnormal electrogram (low-amplitude, fractionated, and long-duration) is notable in sinus rhythm. On the right, pacing at this location produced a nearly perfect QRS match. B: Three-dimensional electroanatomic mapping shows the catheter location at this location. The unipolar electrogram at this site showed a QS signal with the PVC (arrow). C: PVC was suppressed within 20 seconds of cryoenergy application.