title: Outflow tract ventricular arrhythmia originating from the aortic cusps: our approach for challenging ablation.
abstract: BACKGROUND
  Ablation of outflow flow ventricular arrhythmia (VA) originating from aortic cusps can be challenging. The aim of this study was to describe our approach for this ablation.
  
  
  METHODS
  All patients with outflow VA suspected to originate from aortic cusps according to ECG or after failed ablation from right ventricular outflow tract (RVOT) underwent cardiac CT and radiofrequency ablation. CT image of aortic cusps and coronary arteries was integrated into electroanatomic mapping system by point (left main ostium)-based registration. Ablation was performed at the earliest activation site.
  
  
  RESULTS
  Ten patients were included in this case cohort. The ablation catheter was easily maneuvered above and below the aortic valve after registration. Two patients who had previous failed ablation of RVOT focus had successful ablation at right coronary cusp (RCC) and at left coronary cusp (LCC). A patient who had previous failed ablations of RVOT and LCC focuses had successful ablation at RCC-LCC junction. A patient who had previous failed ablation at LCC had successful ablation at RCC-LCC junction. Three patients had successful ablation at RCC-LCC junction, and one patient at LCC. One patient had successful ablation at anterior interventricular vein-great cardiac vein junction. One patient had successful ablation at non-coronary cusp. During follow-up (12-30 months), one patient had recurrence of VA controlled by flecainide. The remaining patients were free of VA without medications.
  
  
  CONCLUSIONS
  Catheter ablation of VA originating from aortic cusps is safe and effective. CT image integration into electroanatomic mapping system can be helpful in this challenging ablation.
authors.affiliation: Division of Pacing and Electrophysiology, Department of Cardiology, Rambam Medical Center, Technion - Israel Institute of Technology, 31096, Haifa, Israel. i_marai@rambam.health.gov.il.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Marai
authors.affiliation: Division of Pacing and Electrophysiology, Department of Cardiology, Rambam Medical Center, Technion - Israel Institute of Technology, 31096, Haifa, Israel.
authors.forename: Monther
authors.initials: M
authors.lastname: Boulos
authors.affiliation: Division of Pacing and Electrophysiology, Department of Cardiology, Rambam Medical Center, Technion - Israel Institute of Technology, 31096, Haifa, Israel.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Lessick
authors.affiliation: Department of Diagnostic Imaging, Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
authors.forename: Sobhi
authors.initials: S
authors.lastname: Abadi
authors.affiliation: Division of Pacing and Electrophysiology, Department of Cardiology, Rambam Medical Center, Technion - Israel Institute of Technology, 31096, Haifa, Israel.
authors.forename: Miry
authors.initials: M
authors.lastname: Blich
authors.affiliation: Division of Pacing and Electrophysiology, Department of Cardiology, Rambam Medical Center, Technion - Israel Institute of Technology, 31096, Haifa, Israel.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Suleiman
mesh_terms: D000328:Adult; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D018780:Body Surface Potential Mapping / Q000379:methods; D016022:Case-Control Studies; D017115:Catheter Ablation / Q000379:methods*; D015331:Cohort Studies; D005260:Female; D006329:Heart Conduction System / Q000000981:diagnostic imaging / Q000601:surgery*; D006352:Heart Ventricles / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging / Q000379:methods; D011247:Pregnancy; D025321:Surgery, Computer-Assisted / Q000379:methods; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000601:surgery*; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D018879:Ventricular Premature Complexes / Q000175:diagnosis / Q000601:surgery*
keywords: Aortic cusps; CT image; Electronatomic mapping; Ventricular arrhythmia