Pulmonary sinus cusp mapping and ablation: A new concept and approach for idiopathic right ventricular outflow tract arrhythmias Jinlin Zhang, MD, Cheng.

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Pulmonary sinus cusp mapping and ablation: A new concept and approach for idiopathic right ventricular outflow tract arrhythmias Jinlin Zhang, MD, Cheng Tang, MD, Yonghua Zhang, MD, Xi Su, MD Heart Rhythm Volume 15, Issue 1, Pages 38-45 (January 2018) DOI: 10.1016/j.hrthm.2017.08.007 Copyright © 2017 Terms and Conditions

Figure 1 Top left: Right ventricular angiography showing the location of the ablation catheter. Top right: Anatomic CARTO map of the right ventricle and RVOT in the posteroanterior view. Yellow tag represents the location of His. Note that the target site was at the posterior and inferior ends of the RVOT, just above the tricuspid annulus. Bottom: Simultaneous recordings of 12-lead ECG and the ablation catheter (ABLd). Local activation of the ablation catheter precedes QRS onset by 32 ms during the premature ventricular contraction. RVOT = right ventricular outflow tract. Heart Rhythm 2018 15, 38-45DOI: (10.1016/j.hrthm.2017.08.007) Copyright © 2017 Terms and Conditions

Figure 2 Fluoroscopy, surface ECG leads, and intracardiac recordings from 3 patients with VAs originating from the AC (A), RC (B), and LC (C). Right anterior oblique (RAO) 30° and left anterior oblique (LAO) 45° radiographic views of the mapping catheter at the successful ablation site as demonstrated by pulmonary artery angiography. Note that 2 components were recorded at the target sites, with the local sharp component (red arrows) following the dull far-field component. A reversed relationship between the 2 components was seen during VAs. ABLd = ablation catheter; ABLuni = unipolar recording of ablation catheter; AC = anterior cusp; LC = left cusp; RC = right cusp; VA = ventricular arrhythmia. Heart Rhythm 2018 15, 38-45DOI: (10.1016/j.hrthm.2017.08.007) Copyright © 2017 Terms and Conditions

Figure 3 Fluoroscopy, electroanatomic map, and intracardiac recordings from a patient with frequent PVCs. Middle bottom: Activation map of the PVCs. Olive green tag represents the earliest activation site, which was located above the PV. Pink tag represents the relatively earlier site in the right ventricular outflow tract region below the PV, which was later than the olive green tag. The distance between the 2 points was 8.2 mm. Middle top: Pulmonary arteriography of left lateral 90° projections, which clearly shows the corresponding location of the olive green tag was in the right cusp (RC). Left: Intracardiac recordings of the olive green tag. Two components were recorded in sinus rhythm, with the sharp near-field component (red arrows) following the blunt far-field component. A reversed relationship between both components during PVCs was present. Noted the QS morphology with notch in the downstroke of the unipolar signal. Right: Intracardiac recordings of the pink tag. Note the single component of the bipolar electrogram and the rS morphology of the unipolar signal. LC = left cusp; PV = pulmonary vein; PVC = premature ventricular contraction. Heart Rhythm 2018 15, 38-45DOI: (10.1016/j.hrthm.2017.08.007) Copyright © 2017 Terms and Conditions

Figure 4 Pace-mapping of a PVC with the PaSo module of the CARTO system. The pacing beats and the selected template were automatically compared. The correlation index was scored between 0 and 1 and labeled on the electroanatomic map. Although the QRS morphology during pacing at the RVOT below the pulmonary valve (blue tag) was very similar to the clinical PVC (0.970), the best match (0.977) was found in the anterior cusp (brown tag). Ablation at this point successfully eliminated the PVC. The shortest perpendicular distance measured from the successful ablation site in the anterior cusp to the ideal mapping site in the RVOT was 23.9 mm. Abbreviations as in Figures 1 and 3. Heart Rhythm 2018 15, 38-45DOI: (10.1016/j.hrthm.2017.08.007) Copyright © 2017 Terms and Conditions

Figure 5 Fluoroscopy, electroanatomic map, surface ECG, and intracardiac recordings from a patient with dextrocardia of complete situs inversus and frequent PVCs. A, B: Ablation catheter (ABLd) at the successful ablation site in the left anterior oblique (LAO) and right anterior oblique (RAO) projections. Note the right position of the cardiac apex due to complete situs inversus. The ablation catheter is located at the corresponding position of the left cusp (LC) in normal heart. C: Shortest perpendicular distance measured from the successful ablation site (pink tag) in the LC to the ideal mapping site in the right ventricular outflow tract below the pulmonary valve (blue tag) was 13 mm. D: Twelve-lead ECG in which limb and precordial leads were recorded in mirror-image fashion. At the target site, 2 components were recorded in sinus rhythm, with the sharp near-field component (red arrows) following the blunt far-field component. A reversed relationship between both components during PVCs was present. PVC = premature ventricular contraction. Heart Rhythm 2018 15, 38-45DOI: (10.1016/j.hrthm.2017.08.007) Copyright © 2017 Terms and Conditions

Figure 6 Upper yellow line was drawn perpendicular to the RVOT long axis (green line) from the level of the lowest PSC bottom (white dashed line, LC). Bottom yellow line was drawn perpendicular to the RVOT long axis from the level of the superior tricuspid valve (blue circle). The measured vertical distance between these 2 lines was 1.87 ± 0.64 cm in the present study. We propose that only the distal part (dashed lines representing 3 PSCs) or inferior end (blue circle) of the RVOT is the true origin of so-called RVOT ventricular arrhythmias. The region between the 2 parts might actually be the exit or the preferential insertion of the conduction pathway. PSC = pulmonary sinus cusp; other abbreviations as in Figures 1 and 2. Heart Rhythm 2018 15, 38-45DOI: (10.1016/j.hrthm.2017.08.007) Copyright © 2017 Terms and Conditions