Key result
Image-guided posteroseptal RVOT ablation immediately suppresses PVCs mimicking a left-sided origin.
Why the study?
ECG localization of ventricular arrhythmias assumes normal cardiac anatomy, but surgical remodeling in adult congenital heart disease can confound traditional algorithms.
Case Report (n=1)
In adult congenital heart disease, anatomical rotation can cause right-sided PVC foci to mimic left-sided origins on ECG, highlighting the importance of cross-sectional imaging for ablation guidance.
ECG algorithms may mislocalize ventricular arrhythmias after congenital heart repair; leaves open need for ACHD-specific validation studies.
BACKGROUND: Electrocardiography (ECG) localization of ventricular arrhythmias assumes normal cardiac anatomy. In cases of adult congenital heart disease, surgical remodeling can confound traditional algorithms. CASE: A 26-year-old male with repaired pulmonary atresia and ventricular septal defect presented with a 17% premature ventricular complexes burden. The ECG showed right bundle branch block morphology, inferior axis, and positive precordial concordance, classically suggesting a left-sided origin. However, cardiac computed tomography revealed extreme clockwise rotation, displacing the right ventricular outflow tract (RVOT) posteriorly. MANAGEMENT: Guided by imaging, mapping prioritized the RVOT. Earliest activation (-20 ms) and a 99% pace-map match were identified at the posteroseptal RVOT. Ablation resulted in immediate suppression, confirming the right-sided origin. CONCLUSIONS: This "left-sided illusion" demonstrates that anatomical rotation can cause right-sided foci to mimic left-sided origins. Integrating cross-sectional imaging with ECG interpretation is critical for guiding ablation strategies in the adult congenital heart disease population.
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Shastry et al. (2026) conducted a case report in Premature ventricular complexes in repaired pulmonary atresia and ventricular septal defect (n=1). Image-guided catheter ablation was evaluated on Suppression of premature ventricular complexes. Image-guided ablation of the posteroseptal RVOT resulted in immediate suppression of premature ventricular complexes in a patient with extreme clockwise cardiac rotation mimicking a left-sided origin.
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