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Ablation of an anteroseptal accessory pathway from the aortic root using electroanatomic mapping
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Ablation of an anteroseptal accessory pathway from the aortic root using electroanatomic mapping Deeptankar DeMazumder, MD, PhD,* Bernadette Barcelon, RTR CV, RCIS, RCES, CEPS,* James Cockrell, MD,† Joseph E. Marine, MD, FHRS* From the *Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, and † Washington Adventist Hospital, Takoma Park, Maryland.
Figure 1
A 31-year-old man with highly symptomatic WolffParkinson-White syndrome refractory to antiarrhythmic drug therapy was referred for catheter ablation. Baseline 12-lead KEYWORDS Wolff-Parkinson-White syndrome; Anteroseptal accessory pathway; Electroanatomic mapping (Heart Rhythm 2014;11:2122–2123) Address reprint requests and correspondence: Dr Joseph E. Marine, Division of Cardiology, Johns Hopkins University School of Medicine, Carnegie 568, 600 North Wolfe St, Baltimore, MD 21287. E-mail address: [email protected].
1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.
electrocardiogram showed manifest ventricular preexcitation with a pattern consistent with anteroseptal accessory pathway (Figure 1A, top). In electrophysiology study, orthodromic atrioventricular reentry tachycardia was easily and reproducibly induced. Electroanatomic mapping, registered with a previously acquired computed tomographic scan of the heart, was performed, and the accessory pathway was mapped during sinus rhythm to a region on the tricuspid annulus adjacent to the His bundle (Figure 1B, yellow dots). Radiofrequency ablation with an open irrigated tip catheter
http://dx.doi.org/10.1016/j.hrthm.2014.06.027
DeMazumder et al
Ablation of an Anteroseptal Accessory Pathway
was performed at the site of earliest ventricular activation on the tricuspid annulus (Figure 1B, red dots) without any change in the accessory pathway conduction. Cryoablation was also performed at right anteroseptal sites unsuccessfully (Figure 1B, white dots). The aortic root was then mapped retrogradely, and a site in the commissure between the right coronary and noncoronary cusps was identified with early ventricular activation, fused atrial and ventricular electrograms, and entirely negative deflection on the unipolar electrogram (Figure 1A). Radiofrequency ablation at this site with 30 W (red arrow) resulted in loss of ventricular preexcitation within a single beat and was continued for 2 minutes. No junctional ectopy was evoked at the effective target site. After ablation, there was no recurrence of accessory pathway conduction and no inducible arrhythmia, and at 6-month follow-up, there was no evidence of recurrent symptoms or pathway conduction. Catheter ablation of anteroseptal accessory pathways poses particular challenges owing to the risk of atrioventricular block. The anatomy of the aortic root makes it an important site to consider for ablation of focal atrial tachycardia arising from the interatrial septum, as well as idiopathic outflow tract ventricular tachycardia and
2123
premature ventricular contractions.1,2 The ablation of anteroseptal pathways from the noncoronary cusp of the aortic root has been described previously and is an important option to consider in these challenging cases.3–5 The use of electroanatomic mapping with merged computed tomographic image in this case was helpful in confirming the anatomical relationships and avoiding ablation near the ostium of the right coronary artery.
References 1. Marine JE, Nazarian S, Bilchick KC, Dong J. Computed tomography in ageguided catheter ablation of a focal atrial tachycardia from the noncoronary sinus of Valsalva. Heart Rhythm 2007;4:1582. 2. Yamada T, Lau YR, Litovsky SH, McElderry HT, Doppalapudi H, Osorio J, Plumb VJ, Kay GN. Prevalence and clinical, electrocardiographic, and electrophysiologic characteristics of ventricular arrhythmias originating from the noncoronary sinus of Valsalva. Heart Rhythm 2013;10:1605–1612. 3. Tada H, Naito S, Nogami A, Taniguchi K. Successful catheter ablation of an anteroseptal accessory pathway from the noncoronary sinus of Valsalva. J Cardiovasc Electrophysiol 2003;14:544–546. 4. Huang H, Wang X, Ouyang F, Antz M. Catheter ablation of anteroseptal accessory pathway in the non-coronary sinus. Europace 2006;8:1041–1044. 5. Suleiman M, Brady PA, Asirvatham, Friedman PA, Munger TA. The noncoronary cusp as a site for successful ablation of accessory pathways: electrogram characteristics in three cases. J Cardiovasc Electrophysiol 2011;22:203–209.
Ablation of an anteroseptal accessory pathway from the aortic root using electroanatomic mapping Deeptankar DeMazumder, MD, PhD,* Bernadette Barcelon, RTR CV, RCIS, RCES, CEPS,* James Cockrell, MD,† Joseph E. Marine, MD, FHRS* From the *Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, and † Washington Adventist Hospital, Takoma Park, Maryland.
Figure 1
A 31-year-old man with highly symptomatic WolffParkinson-White syndrome refractory to antiarrhythmic drug therapy was referred for catheter ablation. Baseline 12-lead KEYWORDS Wolff-Parkinson-White syndrome; Anteroseptal accessory pathway; Electroanatomic mapping (Heart Rhythm 2014;11:2122–2123) Address reprint requests and correspondence: Dr Joseph E. Marine, Division of Cardiology, Johns Hopkins University School of Medicine, Carnegie 568, 600 North Wolfe St, Baltimore, MD 21287. E-mail address: [email protected].
1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.
electrocardiogram showed manifest ventricular preexcitation with a pattern consistent with anteroseptal accessory pathway (Figure 1A, top). In electrophysiology study, orthodromic atrioventricular reentry tachycardia was easily and reproducibly induced. Electroanatomic mapping, registered with a previously acquired computed tomographic scan of the heart, was performed, and the accessory pathway was mapped during sinus rhythm to a region on the tricuspid annulus adjacent to the His bundle (Figure 1B, yellow dots). Radiofrequency ablation with an open irrigated tip catheter
http://dx.doi.org/10.1016/j.hrthm.2014.06.027
DeMazumder et al
Ablation of an Anteroseptal Accessory Pathway
was performed at the site of earliest ventricular activation on the tricuspid annulus (Figure 1B, red dots) without any change in the accessory pathway conduction. Cryoablation was also performed at right anteroseptal sites unsuccessfully (Figure 1B, white dots). The aortic root was then mapped retrogradely, and a site in the commissure between the right coronary and noncoronary cusps was identified with early ventricular activation, fused atrial and ventricular electrograms, and entirely negative deflection on the unipolar electrogram (Figure 1A). Radiofrequency ablation at this site with 30 W (red arrow) resulted in loss of ventricular preexcitation within a single beat and was continued for 2 minutes. No junctional ectopy was evoked at the effective target site. After ablation, there was no recurrence of accessory pathway conduction and no inducible arrhythmia, and at 6-month follow-up, there was no evidence of recurrent symptoms or pathway conduction. Catheter ablation of anteroseptal accessory pathways poses particular challenges owing to the risk of atrioventricular block. The anatomy of the aortic root makes it an important site to consider for ablation of focal atrial tachycardia arising from the interatrial septum, as well as idiopathic outflow tract ventricular tachycardia and
2123
premature ventricular contractions.1,2 The ablation of anteroseptal pathways from the noncoronary cusp of the aortic root has been described previously and is an important option to consider in these challenging cases.3–5 The use of electroanatomic mapping with merged computed tomographic image in this case was helpful in confirming the anatomical relationships and avoiding ablation near the ostium of the right coronary artery.
References 1. Marine JE, Nazarian S, Bilchick KC, Dong J. Computed tomography in ageguided catheter ablation of a focal atrial tachycardia from the noncoronary sinus of Valsalva. Heart Rhythm 2007;4:1582. 2. Yamada T, Lau YR, Litovsky SH, McElderry HT, Doppalapudi H, Osorio J, Plumb VJ, Kay GN. Prevalence and clinical, electrocardiographic, and electrophysiologic characteristics of ventricular arrhythmias originating from the noncoronary sinus of Valsalva. Heart Rhythm 2013;10:1605–1612. 3. Tada H, Naito S, Nogami A, Taniguchi K. Successful catheter ablation of an anteroseptal accessory pathway from the noncoronary sinus of Valsalva. J Cardiovasc Electrophysiol 2003;14:544–546. 4. Huang H, Wang X, Ouyang F, Antz M. Catheter ablation of anteroseptal accessory pathway in the non-coronary sinus. Europace 2006;8:1041–1044. 5. Suleiman M, Brady PA, Asirvatham, Friedman PA, Munger TA. The noncoronary cusp as a site for successful ablation of accessory pathways: electrogram characteristics in three cases. J Cardiovasc Electrophysiol 2011;22:203–209.