Wolff-Parkinson-White syndrome due to a left atrial appendage–to–left ventricular connection: A case of a successful pathway elimination from inside of.

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Wolff-Parkinson-White syndrome due to a left atrial appendage–to–left ventricular connection: A case of a successful pathway elimination from inside of the left atrial appendage Daniel Benhayon, MD, Scarlett Sinisterra, MD, Ming-Long Young, MD, MPH, FHRS HeartRhythm Case Reports Volume 4, Issue 11, Pages 519-522 (November 2018) DOI: 10.1016/j.hrcr.2018.07.016 Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 1 A 12-lead electrocardiogram (ECG) showing a short PR interval with a delta wave positive in V1 and negative in lead I, consistent with a left side accessory pathway. Postablation ECG is shown at the bottom. HeartRhythm Case Reports 2018 4, 519-522DOI: (10.1016/j.hrcr.2018.07.016) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 2 A: Left lateral accessory pathway (AP) ablation site with a distal-to-proximal coronary sinus (CS) retrograde atrial activation sequence during ventricular pacing. B: Activation sequence during ventricular pacing after the first ablation at 3 o’clock on the mitral annulus. With the ablation catheter at the left coronary cusp, the VA signal and a different CS atrial activation sequence are shown. C: Ablation catheter signal at the left atrial appendage (LAA) base during orthodromic reentrant tachycardia (ORT). The local electrogram shows a wide and fragmented signal, starting with the ventricular signal, followed by the pathway potential and the near field atrial signal. The lower left panel shows a right anterior oblique fluoroscopy image with the intracardiac echocardiogram (ICE) catheter sitting in the right ventricular (RV) outflow tract and pointed toward the aortic valve–left atrium–LAA. Also present is the CS catheter, ablation catheter at the time of mitral annulus (MA) ablation, and right atrial and RV catheter. On the right bottom panel is the 3-dimensional map with the sites where the lesions were delivered and marked in order (as 1st, 2nd, and 3rd): 1st corresponds to the first AP ablated at 3 o’clock on the MA; 2nd, to ablation of the second AP on the MA; 3rd, to ablation inside of the LAA base. HeartRhythm Case Reports 2018 4, 519-522DOI: (10.1016/j.hrcr.2018.07.016) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 3 A: Intracardiac echocardiogram (ICE) example of the left atrial appendage (LAA) base relationship to the left ventricle (LV; red circle) and the left coronary cusp region. B: ICE image of the catheter located inside of the LAA base (red circle) where the accessory pathway was successfully eliminated. C: Image of the electroanatomic mapping system reconstruction of the LAA anatomy, and the site of ablation with the recorded signals highlighted. D: Intracardiac recording at the time of ablation at the successful site depicting the orthodromic reentrant tachycardia terminating 3.4 seconds into the ablation. LA = left atrium. HeartRhythm Case Reports 2018 4, 519-522DOI: (10.1016/j.hrcr.2018.07.016) Copyright © 2018 Heart Rhythm Society Terms and Conditions