Europace Advance Access originally published online on July 10, 2008
Europace 2008 10(10):1228-1229; doi:10.1093/europace/eun184
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CASE REPORTS
Successful catheter ablation of premature ventricular contractions originating from the tricuspid annulus using a Halo-type catheter
Division of Cardiovascular Disease, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd Avenue South, Birmingham, AL 35294-0019, USA
Manuscript submitted 5 April 2008. Accepted after revision 23 June 2008.
* Corresponding author. Tel: +1 205 975 4724; fax: +1 205 975 4720. E-mail address: takumi-y{at}fb4.so-net.ne.jp
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A 31-year-old woman with idiopathic premature ventricular contractions originating from the tricuspid annulus (TA) underwent electrophysiological testing. Activation mapping with a 20-pole bipolar Halo-type catheter positioned along the TA revealed the earliest ventricular activation at a site between 7 and 8 o'clock along the TA. A reversal in the polarity of the local ventricular electrograms was observed between the two neighbouring electrode pairs of the TA catheter. Successful catheter ablation was achieved at the ventricular site between those electrode pairs. A Halo-type catheter may be effective for mapping and catheter ablation of ventricular arrhythmias originating from the TA.
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Case report |
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A 31-year-old woman with symptomatic idiopathic premature ventricular contractions (PVCs) was referred for catheter ablation. At baseline, monomorphic PVCs were frequent and exhibited a left bundle branch block and left inferior axis QRS morphology, upright R-waves in leads I, aVL, and V6, and a QS pattern in leads III and aVR (Figure 1). Because those electrocardiographic findings suggested that the PVCs might originate from the tricuspid annulus (TA),1
activation mapping was performed with a deflectable 20-pole bipolar Halo-type catheter (InquiryTM H-Curve, St Jude Medical, AF Division, Minnetonka, MN, USA) positioned on the atrial side along the TA and His-bundle catheter during the PVCs (Figure 1). The earliest ventricular activation that slightly preceded the QRS onset was recorded at a site between 7 and 8 o'clock along the TA. A reversal in the polarity of the local ventricular electrograms was observed between electrode pairs 13–14 and 15–16 of the TA catheter (Figure 1). Radiofrequency applications with a target temperature of 55°C and a maximum power output of 70 W were delivered using an 8 mm tip ablation catheter (Blazer II XPTM 4500THN4, EP Technologies, Boston Scientific Corporation/San Jose, CA, USA) via a pre-shaped long sheath (SR2TM, St Jude Medical, AF Division, Minnetonka, MN, USA) placed at a ventricular site between those electrode pairs where the local ventricular activation preceded the QRS onset by 21 ms and successful ablation was achieved. No complications occurred.
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The majority of the idiopathic ventricular arrhythmias (VAs) have a right or left ventricular outflow tract origin.1
–3 Some uncommon sites of idiopathic VA origins have been revealed,1,4 and the TA may be defined as one of those.1 However, the mapping and catheter ablation of TA VAs may not be fully understood. To the best of our knowledge, this is the first report describing the efficacy of a Halo-type catheter for mapping and catheter ablation of VAs originating from the TA. Because precise positioning of a Halo-type catheter relative to the TA may vary depending on the anatomical features of the TA,5,6 reliance on activation mapping of VAs in the right ventricle may be misleading. During TA VAs, the activation vector along the TA would diverge in opposite directions from the VA origin. Consequently, the bipolar electrograms recorded on either side of the VA origin by a Halo-type catheter positioned along the TA would reflect an opposite polarity to the VA origin site as a boundary. Therefore, the observation of a bipolar electrogram polarity reversal may allow for more precision in the localization of the origin of VAs than identification of the earliest ventricular activation alone. Conflict of interest: T.Y. is supported by a research grant from Boston Scientific and St Jude Medical. A.E.E., G.N.K., H.T.M., and V.J.P. have participated in catheter research funded by Biosense-Webster and Irvine Biomedical. G.N.K. has received honoraria from Medtronic, Boston Scientific, and St Jude Medical. A.E.E. has received honoraria from and served on events committees for Boston Scientific and St Jude Medical. The electrophysiology fellowship programme at the University of Alabama at Birmingham receives funding support from Boston Scientific and Medtronic. The other authors report no conflicts.
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[1] Tada H, Tadokoro K, Ito S, Naito S, Hashimoto T, Kaseno K, et al. Idiopathic ventricular arrhythmias originating from the tricuspid annulus: prevalence, electrocardiographic characteristics, and results of radiofrequency catheter ablation. Heart Rhythm (2007) 4:7–16.[CrossRef][Web of Science][Medline]
[2] Coggins DL, Lee RJ, Sweeney J, Chein WW, Hare GV, Epstein L, et al. Radiofrequency catheter ablation as a cure for idiopathic tachycardia of both left and right ventricular origin. J Am Coll Cardiol (1994) 23:1333–41.[Abstract]
[3] Ouyang F, Fotuhi P, Ho SY, Hebe J, Volkmer M, Goya M, et al. Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp: electrocardiographic characterization for guiding catheter ablation. J Am Coll Cardiol (2002) 39:500–8.
[4] Ito S, Tada H, Naito S, Kurosaki K, Ueda M, Hoshizaki H, et al. Development and validation of an ECG algorithm for identifying the optimal ablation site for idiopathic ventricular outflow tract tachycardia. J Cardiovasc Electrophysiol (2003) 14:1280–6.[CrossRef][Web of Science][Medline]
[5] Anderson RH, Becker AE, Brechenmacher C, Davies MJ, Rossi L. Ventricular preexcitation. A proposed nomenclature for its substrates. Eur J Cardiol (1975) 3:27–36.[Medline]
[6] Anderson RH, Ho SY. Anatomy of the atrioventricular junctions with regard to ventricular preexcitation. Pacing Clin Electrophysiol (1997) 20:2072–6.[CrossRef][Medline]
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