Intramural anterolateral mitral annular idiopathic ventricular tachycardia successfully ablated from the atrium Tawseef Dar, MD, Bharath Yarlagadda,

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Presentation transcript:

Intramural anterolateral mitral annular idiopathic ventricular tachycardia successfully ablated from the atrium Tawseef Dar, MD, Bharath Yarlagadda, MD, Valay Parikh, MD, Y. Madhu Reddy, MD, FHRS, Seth H. Sheldon, MD, FHRS HeartRhythm Case Reports Volume 5, Issue 7, Pages 384-387 (July 2019) DOI: 10.1016/j.hrcr.2019.04.002 Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 1 Event monitor tracing and 12-lead electrocardiogram of ventricular tachycardia. A: Single-channel event monitor tracing demonstrates sinus rhythm with frequent ventricular ectopy including runs of nonsustained ventricular tachycardia. B: A 12-lead electrocardiogram of ventricular tachycardia with right bundle branch block, positive precordial concordance, and right inferior axis suggestive of anterolateral mitral annular exit site. HeartRhythm Case Reports 2019 5, 384-387DOI: (10.1016/j.hrcr.2019.04.002) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 2 Mapping signals at the endocardial left ventricle (LV), adjacent epicardium via the coronary sinus (CS), and the left atrium. A: The earliest endocardial activation in the left ventricle was 15 ms presystolic with a small R wave on the unipolar electrogram. B: The earliest epicardial activation from the distal CS was 28 ms presystolic. C: Far-field activation at the atrial aspect of the mitral annulus was much earlier at 44 ms pre-systolic with an all negative unipolar electrogram. Note the labeled ventricular (V) and atrial (A) electrograms. Ventricular-atrial dissociation was present. The atrial electrogram was near-field. Ablation at site C terminated the ventricular tachycardia within 2 seconds. RV = right ventricular. HeartRhythm Case Reports 2019 5, 384-387DOI: (10.1016/j.hrcr.2019.04.002) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 3 Mitral annular anatomy and proximity to intramural ventricular arrhythmia site of origin. A: Image demonstrates the relationship between the star, which represents the focus of the mitral annular ventricular arrhythmia, and adjacent sites. Site LA, the atrial aspect of the annulus, is in closer proximity to the site of origin than site E (endocardial subvalvular left ventricle) or site CS (epicardial coronary sinus approach). Note the pericardial fat overlying the epicardial aspect of the annulus that would make this region difficult to ablate from a subxiphoid epicardial access. B: CARTO map (Biosense Webster, Diamond Bar, CA) demonstrating red ablation lesions in the endocardial left atrium (site E), epicardial coronary sinus (site CS), and left atrium (LA). The purple dot represents the successful site. (Used with permission from J Cardiovasc Electrophysiol 2010;21:245–254.) HeartRhythm Case Reports 2019 5, 384-387DOI: (10.1016/j.hrcr.2019.04.002) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Supplemental Figure 1 Ventricular tachycardia termination with ablation at the site of earliest activation in the left atrium. Ablation at the site of earliest activation in the left atrium terminated the ventricular tachycardia within 2 seconds. The line on the left marks when ablation was turned on. The far-field ventricular electrocardiogram (EGM) at the successful site is shown. HeartRhythm Case Reports 2019 5, 384-387DOI: (10.1016/j.hrcr.2019.04.002) Copyright © 2019 Heart Rhythm Society Terms and Conditions