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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3651_Библиотеки_им_академика_М_И_Перельмана
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Fig. 4.17 A 12-lead ECG together with intracavitary
leads recorded by the distal bipolar electrode of the ablation catheter (MAP 1–2) placed at the earliest endocardial
activation site in the anterior LVOT, showing the local
ventricular electrogram preceding the onset of the QRS
complex by 14ms. MAP 1 represents the unipolar electrogram recorded by the distal electrode of the roving/ablation catheter and has a “QS” aspect
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F. Halbwachs et al.
Fig. 4.18 CARTO image in RAO 150°, caudal 15° showing the activation map of the right ventricle, the aortic
sinus of Valsalva, and the LVOT during PVC 1, emphasizing the anatomical relationship between the posterior wall
of the RVOT, the left sinus of Valsalva with the origin of
the left coronary artery, and the anterior LVOT. The roving/ablation catheter is positioned in the LVOT, just
Question 8: Is this a good ablation site?
A. Yes. Despite slightly worse ablation cri-
teria compared to the ones recorded in
the left sinus of Valsalva, the earliest
bipolar local electrogram preceding the
surface QRS by 14ms should be enough
for a successful RF application.
B. No. Better ablation criteria were
recorded in the left sinus of Valsalva, so
ablation at this site will probably not
eliminate PVC 1.
C. No. Given the same ablation criteria as
those in the RVOT, ablation should be
tried in the RVOT rst.
D. No. The earliest endocardial activation
in the LVOT precedes the beginning of
the QRS complex by only 14 ms, and
this is usually not good enough for a
successful lesion.
E. I don’t know.
beneath the left main coronary artery. Of note, the earliest
activation site was recorded in the left sinus of Valsalva,
preceding the earliest activation site in the RVOT by 5–6
and by 7–8ms in the LVOT.The local bipolar ventricular
electrogram is shown in the left upper corner in blue, preceding the onset of the QRS complex on the surface ECG
lead II (in white)
The anatomical relationship between the
RVOT, the LVOT and the aortic root is shown
below.
The temporal relationship between the earliest
local activation site during PVC 1 and the onset
of the QRS complex on the 12-lead ECG is presented in Fig.4.19.
Optimal ablation criteria were found in the left
sinus of Valsalva region, at the origin of the left
main coronary artery. However, as said before,
due to a high risk of myocardial infarction associated with RF ablation in this area, this was not
performed in this region. Considered options
were ablation in the posterior part of the high
RVOT, ablation in the anterior LVOT, or terminating the procedure and offering long-term antiarrhythmic treatment. Given the presence of
virtually the same activation delay in LVOT and
RVOT compared to the left sinus of Valsalva
(5–6ms in RVOT and 7–8ms in LVOT), but with
the presence of a “QS” aspect of the local unipolar
electrogram in the LVOT versus an “rS” pattern
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Fig. 4.19 A 12-lead ECG together with intracavitary
leads recorded by the distal and the proximal bipolar electrodes of the ablation catheter (ABL d and ABL p) placed
at the earliest endocardial activation site in the LVOT
showing the local ventricular electrogram preceding the
onset of the QRS complex by 12–14ms. MAP 1 represents the unipolar electrogram recorded by the distal electrode of the roving/ablation catheter
Fig. 4.20 CARTO image in RAO 150°, caudal 15° (same
as in Fig.4.18) showing the activation map of the right
ventricle, the aortic sinus of Valsalva, and the LVOT during PVC 1, just before RF application at the level of the
in the RVOT, ablation in the LVOT was considered as the next best step in the procedure.
RF delivery at the earliest activation site in the
LVOT with a target power of 25W (with energy
titration from 15 to 25W) and a target ablation
earliest activation site in LVOT, which is 7–8ms later than
the earliest activation site in the left sinus of Valsalva. The
bottom of the image shows immediate disappearance of
PVC after RF ablation was turned on (red horizontal line)
index of 450 was applied (Fig.4.20), with immediate elimination of the PVC 1 (Figs. 4.20 and
4.21).
Additional images showing the anatomical
relationship between the RVOT, LVOT, the aortic
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F. Halbwachs et al.
Fig. 4.21 A 12-lead ECG together with intracavitary
leads recorded by the distal and the proximal bipolar electrodes of the ablation catheter (ABL d and ABL p) placed
Fig. 4.22 CARTO image in LAO 20° view showing the
activation map of the basal LV and of the left sinus of
Valsalva during PCV 1. In red, the 3D reconstruction of
the CT angiography images of the coronary arteries is
shown. The red spot at the level of the origin of the left
main coronary artery indicates the earliest local activation
site
sinus of Valsalva, and the coronary arteries are
presented in Figs.4.22 and 4.23.
Next, mapping of PVC 2 was performed.
Given the morphology of PVC2 on the 12-lead
ECG suggesting an origin in the basal and inferior wall of the LV, activation mapping was commenced in the basal LV.
at the earliest endocardial activation site in the LVOT
showing immediate disappearance of PVC after RF ablation was turned on
Fig. 4.23 CARTO image in PA view showing the activation map of the basal LV and of the left sinus of Valsalva
during PCV 1. In red, the 3D reconstruction of the CT
angiography images of the coronary arteries is shown.
The red spot at the level of the origin of the left main coronary artery indicates the earliest local activation site
The activation map of the LV created during
PVC 2 is presented in Figs. 4.24 and 4.25. An
area of early local activation, preceding the onset
of the QRS complex by 19ms, was found at the
level of the basal inferior and septal LV wall. At
this site, the unipolar electrogram recorded by the
distal electrode of the roving/ablation catheter
had à “QS” aspect (Figs.4.26 and 4.27).
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Fig. 4.24 CARTO image in RAO 146° caudal 12° showing the activation map of the LV during PVC 2. The earliest activation area (red color) is recorded by the roving/
ablation catheter in the basal and posterior part of the
LV.The local bipolar ventricular electrogram recorded by
the distal electrode of the roving/ablation catheter is
shown in the left upper corner of the image, in blue, preceding the onset of the QRS complex on the surface ECG
lead II, in white. The superposed cardiac CT angiography
3D reconstruction image of the LV can be seen as the
glass-like, transparent silhouette
Fig. 4.25 CARTO image in RAO 135° caudal 6° showing the activation map of the LV during PVC 2. The earliest activation area (red color) is recorded by the roving/
ablation catheter in the basal and posterior part of the
LV.The local bipolar ventricular electrogram recorded by
the distal electrode of the roving/ablation catheter is
shown in the left upper corner of the image, in blue, preceding the onset of the QRS complex on the surface ECG
lead II, in white. The superposed cardiac CT angiography
3D reconstruction image of the LV can be seen as the
glass-like, transparent silhouette
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F. Halbwachs et al.
Fig. 4.26 A 12-lead ECG together with intracavitary
leads recorded by the distal bipolar electrode of the ablation catheter (MAP 1–2) placed at the earliest endocardial
activation site in the posterior and basal part of the LV,
showing the local ventricular electrogram preceding the
onset of the QRS complex. MAP 1 represents the unipolar
electrogram recorded by the distal electrode of the roving/
ablation catheter and has a “QS” aspect
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Fig. 4.27 A 12-lead ECG together with intracavitary leads recorded by the distal and the proximal bipolar electrodes of the ablation catheter (ABL d and ABL p) placed at the
earliest endocardial activation site in the posterior basal LV showing the local ventricular electrogram preceding the onset of the QRS complex by 19ms
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F. Halbwachs et al.
Question 9: Is this a good ablation site?
A. Yes. The earliest bipolar local electro-
gram precedes the surface QRS by
19ms and this should be enough for a
successful RF lesion. Ablation should
be performed here.
B. Yes. The activation map of the LV indi-
cates a focal mechanism originating
from this site. Ablation should be performed here.
C. Yes. The local unipolar electrogram has
a “QS” aspect, indicating a good ablation site.
D. No. The earliest endocardial activation
in the LV precedes the beginning of the
QRS complex by only 19ms, and this is
usually not good enough for a successful lesion.
E. I don’t know.
RF delivery at this site with a target power of
30 W and a target ablation index of 450 was
applied (Fig.4.28), with immediate elimination
of the PVCs.
After a waiting period of 30min, IV isoprenaline was administered as continuous infusion,
with no PVC observed. There were no complications related to the procedure.
The ECG post-ablation is presented in
Fig.4.29.
The ECG recorded 24h after the ablation is
presented in Fig.4.30.
The patient was discharged from the hospital
48h after the ablation.
Fig. 4.28 CARTO image in RAO 135° caudal 6° showing the activation map of the LV during PVC 2. The earliest activation area (red color) is recorded by the roving/
ablation catheter in the basal and posterior part of the LV,
with superposed RF ablation lesions at the successful
ablation site
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Fig. 4.29 A 12-lead ECG recorded at the end of the ablation procedure showing sinus rhythm with a heart rate of
82bpm, QSR axis at +30°, and absence of PVCs
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Fig. 4.30 A 12-lead ECG recorded the day after the ablation procedure showing sinus rhythm with a heart rate of
82bpm, QSR axis at +30°, and absence of PVCs
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Answers
Question 1: E. Perform catheter
ablation.
Question 2: E.Left sinus of Valsalva.
Question 3: E.Postero-septal wall of the
LV.
Question 4: D. No. The local unipolar
electrogram recorded by the distal
electrode of the roving/mapping cath-
eter has an “rS” pattern.
Question 5: Any of the answers below
are good options
A. Map the coronary sinus to look
for an epicardial origin of the
PVCs.
B. Map the LV.
C. Map the aortic sinus of Valsalva
region.
Question 6: D. No. Despite the good
ablation criteria, ablation at this site
risks to induce acute myocardial
infarction.
Question 7: D.Map the LVOT region.
Question 8: A.Yes. Despite slightly worse
ablation criteria compared to the ones
recorded in the left sinus of Valsalva,
the earliest bipolar local electrogram
preceding the surface QRS by 14ms
should be enough for a successful RF
application.
Question 9:
A. Yes. The earliest bipolar local electro-
gram precedes the surface QRS by
19ms and this should be enough for a
successful RF lesion. Ablation should
be performed here.
B. Yes. The activation map of the LV
indicates a focal mechanism originat-
ing from this site. Ablation should be
performed here.
C. Yes. The local unipolar electrogram
has a “QS” aspect, indicating a good
ablation site.
F. Halbwachs et al.
Commentary
The present case illustrates a catheter ablation
procedure of 2 PVC morphologies: one originating in the left sinus of Valsalva, close to the origin
of the left main coronary artery, and one in the
postero-septal region of the left ventricle, in a
60-year-old female patient with mild LV hypertrophy. Several aspects merit further comments.
PVCs originating from the aortic sinus of
Valsalva represent 16.6–18% of PVCs occurring
in patients with structural normal heart [1, 2].
The most common origins are the RVOT (70–
80% of cases) [3] and the LVOT in 15–25% of
cases [4].
As a general rule, when ablating outow tract
ventricular arrhythmias, mapping should always
be started in the RVOT.This is especially true for
PVCs with a QRS transition in precordial leads in
V3, since approximately 50% of them will have
an RVOT origin and 50% will have a LVOT/coronary cusp origin.
Several criteria have been described on the
12-lead ECG that can orient the identication of
the site of origin of PVCs [4–6]. Elements in
favor of an origin at the level of the aortic sinus of
Valsalva are an early transition in the precordial
leads and the presence of an “rS” pattern in lead
V1 for PVCs originating from the right coronary
cusp [4, 5], a transition in lead V3 and the presence of a “QS” notch in lead V1 for PVCs originating from the junction of the right and left
coronary cusps, and the presence of multiphasic
“M” or “W” in lead V1 for PVCs originating
from the left coronary cusp. The ECG presented
in Fig. 4.1 of our patient has a “QS” pattern in
lead V1, in favor of a right coronary cusp etiology, fact non-conrmed by the activation map of
the aortic sinus of Valsalva performed with the
CARTO system. It should be acknowledged that
the exact site of origin of the PVCs at the level of
the coronary cusps is best identied by intracardiac echography [7], which was not used in the
above-presented case. However, the CT angiography images and the anatomical map of the ori-
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