Trans-subclavian Approach for Radiofrequency Ablation of Atrioventricular Accessory Pathway Associated with Coronary Sinus Diverticulum

Abstract

A 20-year-old Chinese male presented with narrow-complex tachycardia related to type B pre-excitation pattern (Figure 1A and 1B). During the electrophysiological study, the earliest ventricular and atrial activation was adjacent to the coronary sinus (CS) electrode 9,0 during sinus rhythm and 7,8 during ventricular pacing (Figure 1D, 1E and 1G), respectively. An orthodromic atrioventricular reentry tachycardia could be induced reproducibly. Subsequently, a conventional 4 mm tip ablation catheter (Triguy, APT Medical, PRC) was introduced into the right ventricle via a long sheath (SR0, St. Jude Medical, USA). Repeated radiofrequency (RF) energy (50 W at 55 8C) delivery at the target site failed to eliminate the antegrade accessory pathway (AP) conduction due to rising impedance and poor power delivery. Considering the possibility of the AP located at the epicardium, coronary sinus angiography was implemented by Amplatz left 1 catheter. Two CS diverticula were identified near the ostium (Figure 1G, Online Video 1 and 2). A salineirrigated ablation catheter (Triguy, APT Medical, PRC) was reintroduced into the CS via the right femoral vein