A subtype of idiopathic ventricular fibrillation and its relevance to catheter ablation and genetic variants Takahiko Nishiyama, MD, Yoshiyasu Aizawa,

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A subtype of idiopathic ventricular fibrillation and its relevance to catheter ablation and genetic variants Takahiko Nishiyama, MD, Yoshiyasu Aizawa, MD, FHRS, Shogo Ito, MD, Yoshinori Katsumata, MD, Takehiro Kimura, MD, FHRS, Seiji Takatsuki, MD, FHRS, FESC HeartRhythm Case Reports Volume 3, Issue 5, Pages 277-281 (May 2017) DOI: 10.1016/j.hrcr.2017.03.004 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 The 12-lead electrocardiogram (ECG) of the premature ventricular complexes and ECG monitor recording of the ventricular arrhythmia. A: 12-lead ECG. The premature ventricular contraction exhibited a left bundle branch block morphology. The heart rate was 65 beats per minute, and no Brugada-type ECG sign was evident. The PR and QTc intervals were within normal range. B: The ECG monitor recording after admission. A few seconds of premature ventricular complexes were observed preceding the ventricular arrhythmia. HeartRhythm Case Reports 2017 3, 277-281DOI: (10.1016/j.hrcr.2017.03.004) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 The optimal ablation site was guided by intracardiac echocardiography and electroanatomic mapping. A: The CARTO activation mapping image. The electroanatomic image shows the earliest activation site at the free wall of the right ventricle. B: The intracardiac echocardiography imaging of the moderator band in the right ventricle. The purple lines indicate the moderator band. C: The pace mapping from the earliest activation site. D: The intracardiac electrocardiograms at the ablation site. The black arrow shows the sharp potential that preceded the ventricular activation during the premature ventricular complex (PVC). E: A Purkinje potential during sinus rhythm was recorded at the successful ablation site (arrowheads). HeartRhythm Case Reports 2017 3, 277-281DOI: (10.1016/j.hrcr.2017.03.004) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 Ablation at the earliest activation site on the moderator band (MB). A: ICE imaging of the tip of the ablation catheter (Abl) on the moderator band. The arrow shows the catheter in good contact with the moderator band. B: The merge of the CARTO view. The red points indicate the sites where radiofrequency energy was delivered. The purple lines show the moderator band. C: The arrow shows the start of the ablation point. The asterisk demonstrates the suppression of the PVCs, and complete right bundle branch block was induced by the ablation. D: Results of DNA sequencing in a patient demonstrating a heterozygous single T-to-A nucleotide substitution at position 4603 of the ANK2 gene leading to a W1535R missense mutation. HeartRhythm Case Reports 2017 3, 277-281DOI: (10.1016/j.hrcr.2017.03.004) Copyright © 2017 Heart Rhythm Society Terms and Conditions