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Ablation of Left Ventricular Epicardial Outflow Tract Tachycardia From the Distal Great Cardiac Vein

Owen A. Obel, MD^_*, Andre d'Avila, MD, Petr Neuzil, MD, Eduardo B. Saad, MD, Jeremy N. Ruskin, MD^_* and Vivek Y. Reddy, MD^_*,_*

^_* Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Cardiac Arrhythmia Service, Pro-Cardiaco Hospital, Rio de Janeiro, Brazil
Electrophysiology Section, Cardiology Division, Na Homolce Hospital, Prague, Czech Republic

View larger version (40K): [in this window] [in a new window] [Download PPT slide]   Figure 1 The 12-lead electrocardiograms of the ventricular tachycardia from each patient are shown. The numbers 1 through 5 represent patients 1 through 5 as outlined in Table 1.

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 2 Electroanatomical images and electrograms at the time of ablation from Patient 1 and a radiograph of the ablation catheter in Patient 3 as well as a computed tomography (CT) scan illustrating the anatomical relationships of the great cardiac vein (GCV) are shown. (A) Electroanatomical activation mapping of the aortic valve cusps (AVC), the GCV, and the epicardial ventricular surface of the heart (using the subxyphoid pericardial puncture approach) is shown; mapping of the right ventricular outflow tract (RVOT), left ventricular (LV) endocardium, and left atrial appendage (LAA) (not shown) showed late activation. Earliest activation was noted on the ventricular epicardial surface (at the yellow dot). An ablation lesion placed using a cryocatheter at the earliest pericardial activation point only transiently suppressed the VT. (B) The cryoablation catheter was then advanced to the adjacent distal aspect of the GCV (red dot in A)—a site 65 ms earlier than the QRS complex. (C) During the cryoapplication, the VT was eliminated within seconds of freezing of the ablation electrode (indicated by the artifact on the ablation catheter electrogram). (D) A 3-dimensional CT angiographic image of the heart from a left cranial oblique perspective is shown. The parallel courses of the circumflex artery and distal GCV (labeled CS), as well as the LAD artery (and its first diagonal branch) and the AIV can be appreciated. The left AVC and distal CS are in close proximity. (E) An example of the fluoroscopic position of the mapping catheter in the distal GCV is shown.