Elimination of ventricular arrhythmias originating from the anterior interventricular vein with ablation in the right ventricular outflow tract.

Abstract

Idiopathic ventricular arrhythmias not infrequently arise from the left ventricular summit, the superior most portion of the epicardium near the bifurcation of the left main coronary artery.1 These arrhythmias have an inferior axis and usually demonstrate a negative to isoelectric configuration in lead 1. Typically, there is a left bundle branch block pattern in lead V1, with early precordial transition. Often there is a pattern break in lead V2, with a more net negative complex compared with leads V1 and V3. The epicardial left ventricular summit is best accessed for catheter ablation via the coronary venous system.2 However, ablation within the anterior interventricular vein (AIV) can be limited by inability to advance the catheter to the site of interest, inadequate power delivery secondary to impedance/temperature rises, and most importantly, proximity to the left anterior descending (LAD) coronary artery. When one of these limitations is present, ablation can be successful from nearby structures, including the left coronary cusp or left ventricular endocardium.3 We describe for the first time successful elimination of ventricular arrhythmias arising from the left ventricular summit AIV region with ablation from the nearby right ventricular outflow tract (RVOT). A 30-year-old woman presented with palpitations. Holter monitoring revealed a 17% burden of monomorphic ventricular premature depolarizations (VPDs). Transthoracic echocardiogram was normal. After treatment with a β-blocker failed, catheter ablation was performed. Baseline rhythm was sinus with frequent VPDs (right bundle branch block morphology in lead V1, right inferior axis). Activation mapping …