Left sinus of Valsalva—Electroanatomic basis and outcomes with ablation for outflow tract arrhythmias

Abstract

Introduction The ablation of outflow tract premature ventricular contractions (PVCs) is generally safe and effective. In some patients, successful ablation sites may not correlate with the earliest activation. We sought to evaluate mechanistic and anatomic relevance of the region below the left sinus of Valsalva in variable morphology outflow tract ventricular arrhythmias. Methods PVC cases where ablation was in the region inferior to the left sinus of Valsalva were identified. Procedural and demographic information and long‐term outcomes were obtained. Cadaver dissections to evaluate regional anatomy were done as well. Results A total of 51 cases were included (age 53 ± 10; 37 [73%] males). Ablation was done for high PVC burden (>20%; mean 27% ± 8%) and presence of symptoms (73%) or ejection fraction less than 50% (78%). QRS morphology included either R wave (8; 16%), Rs (9; 18%), or rS (67%) in lead I, no precordial transition (40; 78%), V2 transition, (7; 14%), or V3 transition (4; 8%). In 31 (61%), the site just below the left coronary cusp was the earliest site, while the remainder had another site earlier. Ablation was acutely successful in 50 of 51 (98%). After 3 months, success was noted in 48 of 51 (94%). In two patients, repeat ablation in the same region resulted in durable suppression. Conclusion The cases presented emphasize the importance of a region centered below the left sinus of Valsalva, where multivariable morphology QRS may be successfully ablated. Consideration of mapping and ablation even when signals are late in this region may be warranted in previously failed ablation attempts or first‐line evaluation.

Outcomes of single-procedure radiofrequency catheter ablation for idiopathic ventricular arrhythmias: a single-centre retrospective cohort study

“… 17 18 The LV summit PVC/VTs exhibit multiple breakthroughs from RVOT, LVOT and distal cardiac veins. The region could include overlapping multiplanar intercepting myocardium, 19 making it challenging to localise deep intramural true origins that are refractory to conventional ablation. 20 In a recent multicentre study, most cases required repeat ablation and novel approaches such as simultaneous unipolar ablation, bipolar ablation, low-ionic solution irrigation and ethanol ablation.…”

Ablation with zero‐fluoroscopy of premature ventricular complexes from aortic sinus cusps: A single‐center experience

“… 1 Their ablation is challenging due to their proximity to coronary artery ostium (CAO). 2 , 3 , 4 , 5 Coronary catheterization (CC) has conventionally been used to avoid complications during ablation and evaluate the distance from CAO. Over the past few years, there has been an increase in the implementation of zero‐fluoroscopy (ZF) ablation guided by electroanatomical mapping (EAM) systems and imaging techniques.…”

Catheter ablation of ventricular arrhythmias originating from the sinus of valsalva: the reminder from the mapping or ablation in the lower right ventricular outflow tract

“…Moreover, long-standing frequent VAs can result in the arrhythmia-induced cardiomyopathy irrespective of arrhythmic symptoms [2] . Radiofrequency (RF) ablation has been acknowledged as a safe and preferred therapy for eradicating the drug-refractory outflow-tract VAs [3][4][5] , with a success rate of 80-95% [1,3,6] . Nevertheless, VAs origins arising from the right or left ventricular outflow tract sometimes can exhibit a similar QRS configuration of LBBB pattern with an inferior axis [4] , especially VAs originating from the SoV could exhibit the trivial electrocardiographic difference from VAs arising from the lower RVOT.…”