Idiopathic Ventricular Arrhythmias Originating From the Aortic RootPrevalence, Electrocardiographic and Electrophysiologic Characteristics, and Results of Radiofrequency Catheter Ablation
Takumi Yamada, MD*,*,
H. Thomas McElderry, MD*,
Harish Doppalapudi, MD*,
Yoshimasa Murakami, MD ,
Yukihiko Yoshida, MD ,
Naoki Yoshida, MD,
Taro Okada, MD,
Naoya Tsuboi, MD,
Yasuya Inden, MD#,
Toyoaki Murohara, MD#,
Andrew E. Epstein, MD*,
Vance J. Plumb, MD*,
Satinder P. Singh, MD and
G. Neal Kay, MD*
* Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
Division of Cardiology, Aichi Prefectural Cardiovascular and Respiratory Center, Ichinomiya, Japan
Division of Cardiology, Nagoya Dai-ni Red Cross Hospital, Cardiovascular Center, Nagoya, Japan
# Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Figure 1 Successful Ablation Site of PVCs Originating From the L-RCC
The first beat is a sinus beat and the second is a premature ventricular contraction (PVC). At the successful ablation site, 2 ventricular activation components and no atrial activations were recorded during sinus rhythm (left panel). The sequence of the 2 components was reversed during the PVCs. The first of the 2 components preceded the QRS onset by 65 ms. The aortagram showed that the ablation catheter was located in the junction of the left and right aortic sinus cusps (L-RCC) (center panels). Note that the tip of the ablation catheter was positioned at the L-RCC by deflecting the loop of the ablation catheter in the left ventricular cavity. The activation map during the PVCs revealed the earliest activation at the L-RCC (right panels). ABLd = distal electrode pair of the ablation catheter; ABLp = proximal electrode pair of the ablation catheter; ABLuni = distal unipolar electrode of the ablation catheter; AP = anteroposterior; LAO = left anterior oblique view; LCC = left coronary cusp; LL = left lateral; LVOT = left ventricular outflow tract; RAO = right anterior oblique view; RCC = right coronary cusp; RVOT = right ventricular outflow tract.
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Figure 2 Ablation Sites of a VT Originating From the NCC Near the HB and in the NCC
Radiofrequency applications delivered near the His bundle (HB) region where the local ventricular activation preceded the QRS onset by 25 ms (left panel) caused a slight change in the QRS morphology with the prolongation of the QRS duration and an attenuation and delay of the high-amplitude near-field ventricular electrogram in the HB region (double arrowheads, center panel). The low-amplitude far-field ventricular electrogram (single arrowheads, center panel) preceding the QRS onset was then separated from the near-field ventricular electrogram after the QRS onset in the HB region. Successful radiofrequency ablation was achieved in the noncoronary cusp (NCC) where the local ventricular activation was recorded simultaneously with the activation of the far-field ventricular electrogram in the HB region (center panel). Note that the atrial electrogram with an amplitude greater than that of the ventricular electrogram was recorded at the successful ablation site during sinus rhythm (right panel). HBd = distal electrode pair of the His catheter; HBp = proximal electrode pair of the His catheter; VT = ventricular tachycardia; other abbreviations as in Figure 1.
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Figure 3 Successful Ablation Site of a PVC Originating From the Right Coronary Cusp
The first beat is a sinus beat and the second is a premature ventricular contraction (PVC). At the successful ablation site, atrial and His bundle (HB) (arrows) electrograms were recorded during sinus rhythm and during the PVC; a far-field electrogram (single arrowhead) preceding the QRS onset by 18 ms and the following near-field electrogram (double arrowheads) were observed in the right ventricular HB region. Abbreviations as in Figures 1 and 2.
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Figure 4 Cardiac Tracings Exhibiting the Termination of a Sustained Ventricular Tachycardia Originating From the Right Coronary Cusp by Probable Mechanical Pressure of the Ablation Catheter at the Successful Ablation Site
RVd = distal electrode pair of the right ventricular catheter; RVp = proximal electrode pair of the right ventricular catheter; other abbreviations as in Figures 1 and 2.
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Figure 5 Two-Dimensional Computerized Tomography Image and Representative 12-Lead Electrocardiograms of Premature Ventricular Contractions or Ventricular Tachycardia Originating From the Aortic Root
L = left coronary cusp; LA = left atrium; N = noncoronary cusp; R = right coronary cusp; RA = right atrium; RV = right ventricle.
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Figure 6 Two-Dimensional Computerized Tomography Images Showing the Relationships Between the Ventricular Myocardium and Aortic Sinus Cusps
Arrowheads indicate the distal edge of the ventricular myocardium connecting with the left coronary cusp (L) and right coronary cusp (R), and the dotted line (right panel) indicates the ventriculoarterial junction (the ostium of the left ventricle [LV]). Ao = aorta; LCA = left coronary artery; MV = mitral valve; other abbreviations as in Figure 5.
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