Ablation of ventricular arrhythmias arising near the anterior epicardial veins from the left sinus of Valsalva region: ECG features, anatomic distance, and outcome.
BACKGROUND
Left ventricular outflow tract tachycardia/premature depolarizations (VT/VPDs) arising near the anterior epicardial veins may be difficult to eliminate through the coronary venous system.


OBJECTIVE
To describe the characteristics of an alternative successful ablation strategy targeting the left sinus of Valsalva (LSV) and/or the adjacent left ventricular (LV) endocardium.


METHODS
Of 276 patients undergoing mapping/ablation for outflow tract VT/VPDs, 16 consecutive patients (8 men; mean age 52 ± 17 years) had an ablation attempt from the LSV and/or the adjacent LV endocardium for VT/VPDs mapped marginally closer to the distal great cardiac vein (GCV) or anterior interventricular vein (AIV).


RESULTS
Successful ablation was achieved in 9 of the 16 patients (56%) targeting the LSV (5 patients), adjacent LV endocardium (2 patients), or both (2 patients). The R-wave amplitude ratio in lead III/II and the Q-wave amplitude ratio in aVL/aVR were smaller in the successful group (1.05 ± 0.13 vs 1.34 ± 0.37 and 1.24 ± 0.42 vs 2.15 ± 1.05, respectively; P = .043 for both). The anatomical distance from the earliest GCV/AIV site to the closest point in the LSV region was shorter for the successful group (11.0 ± 6.5 mm vs 20.4 ± 12.1 mm; P = .048). A Q-wave ratio of <1.45 in aVL/aVR and an anatomical distance of <13.5 mm had sensitivity and specificity of 89%, 75% and 78%, 64%, respectively, for the identification of successful ablation.


CONCLUSIONS
VT/VPDs originating near the GCV/AIV can be ablated from the LSV/adjacent LV endocardium. A Q-wave ratio of <1.45 in aVL/aVR and a close anatomical distance of <13.5 mm help identify appropriate candidates.
Electrophysiology Section, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
Miguel E
ME
Jauregui Abularach
Bieito
B
Campos
Kyoung-Min
KM
Park
Cory M
CM
Tschabrunn
David S
DS
Frankel
Robert E
RE
Park
Edward P
EP
Gerstenfeld
Stavros E
SE
Mountantonakis
Stavros
S
Mountantonakis
Fermin C
FC
Garcia
Sanjay
S
Dixit
Wendy S
WS
Tzou
Mathew D
MD
Hutchinson
David
D
Lin
Michael P
MP
Riley
Joshua M
JM
Cooper
Rupa
R
Bala
David J
DJ
Callans
Francis E
FE
Marchlinski
D017115:Catheter Ablation / Q000379:methods*; D004452:Echocardiography; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium; D012189:Retrospective Studies; D012850:Sinus of Valsalva / Q000294:innervation / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D014680:Veins; D018879:Ventricular Premature Complexes / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*