Ablation of a Para-Hisian Accessory Pathway from the Non-coronary Cusp: A Case Report.

Figures

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  Figure 1:. Electrocardiogram after pharmacological cardioversion demonstrating delta waves suggestive of a right anteroseptal accessory pathway.

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  Figure 2:. Three-dimensional mapping using CARTO™ and UniVu™; shown here is the site of initial ablation on the right anterior septal region, showing its proximity to the His region. The red dots represent the radiofrequency applications, and the yellow dots represent where His signals were identified. On the left is the right anterior oblique view and on the right is the left anterior oblique view.

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  Figure 3:. Intracardiac echocardiography showing the quadripolar catheter (1) located in the right atrium at the His region just across the non-coronary cusp (NCC) and the ablation catheter (2) positioned at the NCC of the aortic valve.

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  Figure 4:. Pre-ablation intracardiac electrocardiogram from the non-coronary cusp.

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  Figure 5:. Moment of interruption of stimulus conduction through the accessory pathway. The first three beats are pre-excited, and there is an accessory pathway block on the fourth beat (without pre-excitation). The bottom of the electrogram shows the time running; radiofrequency energy was applied for 2 s until interruption of the accessory pathway.

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  Figure 6:. Mapping with CARTO™ and UniVu™ showing retroaortic access and the sites where radiofrequency applications were delivered in the non-coronary cusp (red points), as well as the His region (yellow points). A quadripolar catheter was positioned at the His bundle, and a decapolar catheter was positioned in the coronary sinus.

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  Figure 7:. Final electrocardiogram after ablation without pre-excitation.