Volume 15, Issue 1, Pages (January 2018)

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Volume 15, Issue 1, Pages 81-89 (January 2018) Idiopathic ventricular arrhythmias originating from the right coronary sinus: Prevalence, electrocardiographic and electrophysiological characteristics, and catheter ablation Yunlong Wang, MD, Zhuo Liang, MD, Shaoqin Wu, MD, Zhihong Han, MD, Xuejun Ren, MD Heart Rhythm Volume 15, Issue 1, Pages 81-89 (January 2018) DOI: 10.1016/j.hrthm.2017.09.008 Copyright © 2017 Terms and Conditions

Figure 1 Electrocardiogram of 9 consecutive patients in the right coronary sinus (RCC) group. A surface electrocardiogram shows a typical left bundle-branch block morphology with an inferior axis in these 9 patients. Heart Rhythm 2018 15, 81-89DOI: (10.1016/j.hrthm.2017.09.008) Copyright © 2017 Terms and Conditions

Figure 2 Mapping and electrograms in the right ventricular outflow tract (RVOT) in the right coronary sinus (RCC) group. A: The earliest activation site (EAS) (blue point) was localized in the middle septal region of the RVOT, and a small area of double or complex potentials (white point) was recorded surrounding the EAS. B–E: The activation map of the septal region of the RVOT revealed that the activation propagated from the middle septal toward the superior and inferior septal regions. Yellow point: His bundle. Heart Rhythm 2018 15, 81-89DOI: (10.1016/j.hrthm.2017.09.008) Copyright © 2017 Terms and Conditions

Figure 3 Electrograms recorded at the right ventricular outflow tract (RVOT) and the right coronary cusp (RCC) in the RCC group. A: The earliest activation site (EAS) potential recorded at the RVOT was complicated and preceded QRS complex onset by 32 ms. B: A poor pace map match was obtained at the EAS of the RVOT. C: The potential (P1) recorded in the RCC was special (arrow) and preceded QRS complex onset by 36 ms. D: A perfect pace mapping could not be achieved. ABL = ablation catheter; d, p = distal and proximal electrode pairs, respectively. Heart Rhythm 2018 15, 81-89DOI: (10.1016/j.hrthm.2017.09.008) Copyright © 2017 Terms and Conditions

Figure 4 Mapping and measurement in the right ventricular outflow tract (RVOT) and aortic sinus cusp (ASC) in different groups. The distance between the His bundle (HB) and the earliest activation site (EAS) in the septal RVOT was A and B: 22.8 mm in the right coronary cusp (RCC) group, C and D: 55 mm in the left coronary cusp (LCC) group, and E: 33.8 mm in the RVOT group. F: A cutoff value of ≤29.4 mm rules out RVOT and LCC origin, and had 92.6% sensitivity and 100% specificity for RCC origin. G: The distance between the EAS of the RVOT and successful ablation site at ASC was shorter in RCC group compared with that in the H and I: LCC group. Yellow point: His bundle. White point: RCC. Deep blue point: LCC. Pink point: noncoronary sinus. Light blue point in RVOT: EAS. Light blue point in ASC: the successful ablation site. n = 27 in the RCC group. n = 50 in the RVOT group. n = 9 in the LCC group. Heart Rhythm 2018 15, 81-89DOI: (10.1016/j.hrthm.2017.09.008) Copyright © 2017 Terms and Conditions

Figure 5 Angiogram of the coronary artery and aorta and intracardiac echocardiography showing catheter tip at successful ablation site in the right coronary cusp (RCC). The distance from the successful ablation site to the right coronary artery ostium was 13.2 mm and to the bottom of RCC was 7.1 mm in the A: right anterior oblique (RAO) and B: left anterior oblique (LAO) views. C: Intracardiac echocardiogram confirmed that the ablation catheter tip was located at anterior and upper aspects of the RCC. NCC = noncoronary sinus; PA= pulmonary artery. Heart Rhythm 2018 15, 81-89DOI: (10.1016/j.hrthm.2017.09.008) Copyright © 2017 Terms and Conditions

Figure 6 Premature ventricular contractions were successfully ablated below the aortic valve in 1 patient. A: An early and small P1 potential (arrow) was recorded at the right coronary cusp (RCC), but ablation was ineffective. B: An early and higher P1 potential (arrow) was recorded at RCC, but ablation was only transiently effective. C: A small but very early P1 potential (arrow) was recorded below the aortic valve, and ablation was successful. D: Intracardiac echocardiogram and E and F: CARTO imaging confirmed that the ablation catheter tip was located below the aortic valve at almost the same level of the ablation sites of the RCC. AO = aorta; LA = left atria; LV = left ventricle. Blue point: left coronary cusp. Pink point: RCC. Yellow point: noncoronary sinus. Red point: ablation site. White point: left main coronary artery. Heart Rhythm 2018 15, 81-89DOI: (10.1016/j.hrthm.2017.09.008) Copyright © 2017 Terms and Conditions

Figure 7 Comparison of electrograms from ablation sites in the aortic sinus cusp. P2 potential (arrowhead) was infused in the ventricular potential in sinus rhythm, and spontaneous reversal could be recorded during ventricular arrhythmias, which was defined as P1 potential (arrows) at that time. The interval from P1 potential to QRS complex onset was A: 22 ms, B: 44 ms, and C: 44 ms at 3 unsuccessful ablation sites in the right coronary cusp (RCC), respectively. P1 potential amplitude was A: 0.134 mV, B: 0.154 mV, and C: 0.247 mV at 3 unsuccessful ablation sites in the RCC, respectively. D: P1 potential amplitude (0.371 mV) was obviously higher at successful ablation sites under the circumstance of approximately the same interval (44 ms) from P1 potential to QRS complex onset, compared with that of unsuccessful ablation sites. E: The interval from P1 potential to QRS complex onset was 44 ms at successful ablation sites in the left coronary cusp. In contrast, P1 potential amplitude at successful ablation sites in LCC was 0.095 mV, which was obviously lower than that in the RCC group. Heart Rhythm 2018 15, 81-89DOI: (10.1016/j.hrthm.2017.09.008) Copyright © 2017 Terms and Conditions