Fluoroless Ablation of a Coronary Sinus-related Accessory Pathway Without Coronary Sinus Angiogram in a Patient with Multiple Prior Failed Ablations.

Figures

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  Figure 1:. Twelve-lead electrocardiogram (ECG) demonstrating manifest pre-excitation. The ECG shows a short P–R interval with a delta wave and an immediately negative QRS complex in the inferior leads (II, III, and aVF), consistent with an epicardial accessory pathway.

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  Figure 2:. Three-dimensional electroanatomic map of the superior vena cava (SVC), inferior vena cava (IVC), right atrium (RA), and coronary sinus (CS) showing the ablation catheter at position in relation to the CS catheter.

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  Figure 3:. Intracardiac electrograms showing a short H–V interval of 29 ms.

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  Figure 4:. Narrow complex tachycardia inducible with a cycle length of 340 ms.

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  Figure 5:. Ventricular entrainment of the tachycardia resulted in repeated termination of the tachycardia. However, the first stable ventricular beat entrained the tachycardia in a manner suggestive of orthodromic reciprocating tachycardia.

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  Figure 6:. Ablation delivered at the site of the earliest ventricular signal recorded on the mapping system.

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  Figure 7:. A fused local atrioventricular signal and a QS pattern noted on the unipolar electrode.

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  Figure 8:. Post-ablation H–V interval of 45 ms.

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  Figure 9:. A separated atrioventricular signal noted on the ablation target site after ablation.

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  Figure 10:. A: Ventricular pacing after administration of 18 mg of adenosine demonstrating loss of retrograde conduction over the accessory pathway. B: Post-ablation electrocardiogram demonstrating loss of pre-excitation.