Ablation of VT Originating from Left Coronary Sinus of Valsalva - - PDF document

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10/27/2013 Ablation of VT Originating from Left Coronary Sinus of Valsalva Ni Nine netee teen n yr yr-old old male pr male prese esente nted d wi with th rec ecur urren ent e t episo pisode des s of of r rapid pa pid

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10/27/2013 1

Ablation of VT Originating from Left Coronary Sinus of Valsalva

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nt. No history

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SLIDE 2

10/27/2013 2

Gen Gener eral: al:

BP BP = = 110 110/60 60, , HR HR = = 70 70/mi /min, of n, of a aver erage ge vol

, eq equa ual l on

n both

both si side des an s and d pe peri riph pher erall ally f y felt, elt, no no L LL L ed edema ema, , che hest w st was as clear lear. . pu pulse lse sh shows f ws freq eque uent nt full fully co y compe mpensa nsated ted extr xtrasy asystoles stoles (> (>10 10/mi /min). n).

Car Cardiac diac: :

Nor Normal mal S1, , S2, , no no ad additi dition

al so soun unds o ds or r mur murmur murs. s.

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10/27/2013 3

Echocardiography: EP study and ablation: (Done 6 ms ago)

Normal study Activation mapping showed a focus originating from LVOT. Results: Disappearance of VT and NSVT with and without induction, but PVCs persisted. One month later, patient developed recurrence of VT on 24 h Holter recording.

Plan:

For repeat ablation using CARTO

Baseline ECG: Spontaneous frequent V ectopy and NSVT

Rep epea eat t EPS EPS

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10/27/2013 4

CARTO mapping

LV

LM Coronary angiogram

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10/27/2013 5 Activation mapping

PVC Site of origin

25 ms

Lt guiding was used.. wire was placed in LM during ablation

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10/27/2013 6

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10/27/2013 7 Propagation map Post ablation ECG Pre ablation ECG

SLIDE 8

10/27/2013 8 Prevalence  Is a variant of LVOT VT.  Up to 18% of idiopathic VTs/PVCs.  More likely to arise from the LC sinus than from the RC sinus and are rare in the NC sinus.  Rarely may present as RVOT VT when myocardial bridging between RC sinus and RVOT with preferential conduction.

The right and left coronary sinuses incorporate ventricular musculature at their base but the non-coronary sinus is exclusively composed of fibrous walls

Anatomic considerations

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10/27/2013 9

The hinge of the valvular leaflet is attached to the ventricular myocardium well proximal to the anatomic ventriculo- arterial junction

Heart2000;84:670-673 doi:10.1136/heart.84.6.670

V5 V6 LVOT-VT: Supravalvular focus: Absent S in V5, V6 Infravalvular focus: S in V5, V6 Sensitivity 100% Specificity 88%

Hachiya H, et al. . How to diagnose, locate, and ablate coronary cusp ventricular tachycardia. J Cardiovasc Electrophysiol 2002;13:551-6.

SLIDE 10