Outflow tract tachycardia with R/S transition in lead V3
Six different anatomic approaches for successful ablation
Hildegard Tanner, MD*,
Gerhard Hindricks, MD,
Petra Schirdewahn, MD,
Richard Kobza, MD,
Anja Dorszewski, MD,
Christopher Piorkowski, MD,
Jin-Hong Gerds-Li, MD and
Hans Kottkamp, MD
University of Leipzig-Heart Center, Cardiology, Department of Electrophysiology, Leipzig, Germany
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Figure 1 Twelve-lead surface ECG from six different patients with idiopathic ventricular tachycardia that was successfully ablated in the right ventricular outflow tract (RVOT), in the left ventricular outflow tract (LVOT), in the aortic sinus of Valsalva (AO), in the coronary sinus (CS), in the main pulmonary artery (PA), and in the epicardial space via percutaneous pericardial access (EPI), respectively. Note that all ECGs present with left bundle-branch block morphology, inferior axis, R/S transitional zone in the precordial leads V3, and negative QRS complex in lead I.
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Figure 2 Example of a successful ablation of frequent premature ventricular complexes from the left ventricular outflow tract (LVOT). (A) Shown are both unipolar (Abl uni) and bipolar (Abl bi) electrograms from the ablation catheter positioned at the LVOT. (B and C) Radiograms obtained in the right anterior oblique (RAO 30°) (B) and left anterior oblique (LAO 60°) view (C) show the successful ablation site. The distal electrodes of the ablation catheter (ABL) are positioned in the LVOT just below the left coronary cusp of the aortic valve in the region of the aortomitral continuity. Schematic drawings present the position of the aortic valve area (AV) and the mitral annulus (MA). CS = coronary sinus; RVA = right ventricular apex.
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Figure 3 Example of a successful ablation of an idiopathic ventricular tachycardia from the aortic sinus of Valsalva. (A) The endocardial electrogram recorded from the ablation catheter precedes the QRS complex by 55 ms. The bipolar electrogram at the successful ablation site shows a split aortic part (AO) and left ventricular part (LV) presenting a slight conduction delay from the aorta to the left ventricular myocardium. Other abbreviations as in Figure 2. (B) Left ventricular outflow tract electroanatomic activation map including the aortic sinus of Valsalva during idiopathic ventricular tachycardia is shown, with red color indicating the earliest activation time. The tip of the ablation catheter is located at the successful ablation site in the aortic sinus of Valsalva. (C and E) The radiograms show the ablation catheter (ABL) at the successful ablation site in the non-coronary cusp. (D and F) The aortogram show the aortic sinus of Valsalva with schematically highlighted coronary arteries. AV = aortic valve area; LAD = left anterior descending artery; LCX = left circumflex artery; LM = left main coronary artery; PA = pulmonary artery; RCA = right coronary artery. Other abbreviations as in Figures 2 and 3.
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Figure 4 Example of a successful ablation of an idiopathic ventricular tachycardia (VT) from the great cardiac vein via the coronary sinus. (A) The electrogram recorded from the ablation catheter precedes the QRS complex by 45 ms. (B) A 12-lead surface ECG of the idiopathic VT is shown at the left half of the panel. On the right half, a perfect pacemap obtained at the successful ablation site is shown. (C and D) Coronary sinus (CS) electroanatomic activation maps during idiopathic VT are shown. Red color indicates the earliest activation time. The dark red dot represents the successful ablation site (ABL) in the great cardiac vein. AV = aortic valve area; CSO = coronary sinus ostium; GCV = great cardiac vein. (E and F) Radiograms show the successful ablation site. LAD = left anterior descending artery; LCX = left circumflex artery. Other abbreviations as in Figures 2 and 3.
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Figure 5 Example of a successful ablation of an idiopathic ventricular tachycardia from the pulmonary artery (PA). (A) Shown are both unipolar (Abl uni) and a sharp bipolar (Abl bi) electrograms from the ablation catheter positioned at the PA. RVA = right ventricular apex. (B and C) Right ventricular electroanatomic activation maps including the proximal part of the pulmonary artery are shown, with red color indicating the earliest activation time. Gray color represents schematically the region of the pulmonary valve (PV). The dark red dot represents the successful ablation site (ABL) in the pulmonary artery. RVOT = right ventricular outflow tract; TA = tricuspidal annulus. (D and E) Radiograms show the successful ablation site. LAO 60° = left anterior oblique view; RAO 30° = right anterior oblique view.
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Figure 6 Example of a successful ablation of idiopathic ventricular tachycardia from the epicardium through a percutaneous pericardial access. (A) Shown are both unipolar (Abl uni) and bipolar (Abl bi) electrograms from the ablation catheter positioned at the LVOT. (B and C) Epicardial electroanatomic activation maps during frequent premature ventricular complexes are shown. Red color indicates the earliest activation time. The dark red dots represent the successful ablation site (ABL). (D and E) Radiograms show the successful ablation site in relation to the left coronary arteries. Other abbreviations as in Figures 2 and 3.
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