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Zhou ZX, Zheng C, Hu YD, Lin JF. Mapping and ablation of ventricular arrhythmias arising from the left ventricular summit. Pacing Clin Electrophysiol 2024; 47:242-252. [PMID: 38291856 DOI: 10.1111/pace.14932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024]
Abstract
The left ventricular summit (LVS) refers to the highest portion of the left ventricular outflow tract (LVOT). It is an epicardially delimited triangular area by the left coronary arteries and the coronary venous circulation. Its deep myocardium correlates closely with the left coronary cusp, aortic-mitral continuity, and right ventricular outflow tract (RVOT), complicating the anatomical relationship. Ventricular arrhythmias (VAs) originating from this area are common, accounting for 14.5% of all VAs origin from left ventricle. Specific electrocardiogram (ECG) characteristics may assist in locating LVS-VAs pre-procedure and facilitate procedure planning. However, catheter ablation of LVS-VAs remains challenging because of anatomical constraints. This paper reviews the recent understanding of LVS anatomy, concludes ECG characteristics, and summarizes current mapping and ablation methods for LVS-VAs.
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Affiliation(s)
- Zhi-Xiang Zhou
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Cheng Zheng
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - You-Dong Hu
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jia Feng Lin
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Kuniewicz M, Budnicka K, Dusza M, Jakob N, Cholewa N, Defonseka R, Gosnell M, Wadhwa T, Walocha J, Dobrzynski H, Hołda M. Gross anatomic relationship between the human left atrial appendage and the left ventricular summit region: implications for catheter ablation of ventricular arrhythmias originating from the left ventricular summit. J Interv Card Electrophysiol 2023; 66:301-310. [PMID: 35262858 DOI: 10.1007/s10840-022-01172-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The left ventricular summit (LVS) is a source of difficult-to-treat arrhythmias because of anatomical limitations. The aim of this study was to perform detailed research of the left atrial appendage (LAA) anatomy of cadaveric hearts to analyze their complex anatomy and coverage of the LVS. METHODS AND RESULTS Eighty human formalin fixed hearts (mean age 44.4 ± 15.5, 27.5% females) were investigated. Each LAA size, type, and its relationship to the LVS were analyzed, as well as possible access sites for mapping/ablating electrode. Four types of LAA were observed over two LVS sites that are either accessible or not. The highest coverage over an inaccessible LVS area was observed in the Broccoli type, followed by the Windsock then the Chicken Wing and finally the Cactus types; over the accessible area of the LVS was observed in the Windsock, then in the Chicken Wing, then in the Cactus, and finally in the Broccoli types. The attainable coverage for electrode access is diminished from 25 to 65% because of the complex pectinate muscles and sharp angles. The highest density of the LAA floor made by pectinate muscles can be found in the Broccoli type (p < 0.005), while the Chicken Wing had the highest number of paper-thin-like pouches. CONCLUSIONS The LAA appears to be a promising entry for ablation-qualified patients with the LV summit originate arrhythmias. The complex internal structure of the LAA may complicate ablation procedures. More prominent appendages are promising in more extensive mapping areas over the LVS.
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Affiliation(s)
- M Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland. .,Department of Electrocardiology, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland.
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Dusza
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Cholewa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - R Defonseka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - T Wadhwa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - H Dobrzynski
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - M Hołda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
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Left atrial appendage as a vantage point for targeting ventricular arrhythmias originating from the left ventricular summit: "Get to know your neighbors". J Interv Card Electrophysiol 2023; 66:241-242. [PMID: 35318577 DOI: 10.1007/s10840-022-01184-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
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Yamada T. Techniques for Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating from the Outflow Tract and Left Ventricular Summit. Card Electrophysiol Clin 2022; 14:621-631. [PMID: 36396181 DOI: 10.1016/j.ccep.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Idiopathic ventricular arrhythmias (VAs) most commonly originate from the ventricular outflow tracts. Because the anatomy of this region is complex and some of those VA origins are intramural and epicardial, it may sometimes be difficult to locate the site of the VA origin. Meticulous mapping in multiple different locations such as the right and left ventricular outflow tracts, endocardial and epicardial sites, and above and below the aortic and pulmonic valves may be required to achieve successful catheter ablation of those VAs. Special ablation techniques may be considered to improve the outcome of catheter ablation of intramural and epicardial VAs.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA.
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Left Ventricular Summit-Concept, Anatomical Structure and Clinical Significance. Diagnostics (Basel) 2021; 11:diagnostics11081423. [PMID: 34441357 PMCID: PMC8393416 DOI: 10.3390/diagnostics11081423] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 01/18/2023] Open
Abstract
The left ventricular summit (LVS) is a triangular area located at the most superior portion of the left epicardial ventricular region, surrounded by the two branches of the left coronary artery: the left anterior interventricular artery and the left circumflex artery. The triangle is bounded by the apex, septal and mitral margins and base. This review aims to provide a systematic and comprehensive anatomical description and proper terminology in the LVS region that may facilitate exchanging information among anatomists and electrophysiologists, increasing knowledge of this cardiac region. We postulate that the most dominant septal perforator (not the first septal perforator) should characterize the LVS definition. Abundant epicardial adipose tissue overlying the LVS myocardium may affect arrhythmogenic processes and electrophysiological procedures within the LVS region. The LVS is divided into two clinically significant regions: accessible and inaccessible areas. Rich arterial and venous coronary vasculature and a relatively dense network of cardiac autonomic nerve fibers are present within the LVS boundaries. Although the approach to the LVS may be challenging, it can be executed indirectly using the surrounding structures. Delivery of the proper radiofrequency energy to the arrhythmia source, avoiding coronary artery damage at the same time, may be a challenge. Therefore, coronary angiography or cardiac computed tomography imaging is strongly recommended before any procedure within the LVS region. Further research on LVS morphology and physiology should increase the safety and effectiveness of invasive electrophysiological procedures performed within this region of the human heart.
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Kamioka M, Hijioka N, Nodera M, Yamada S, Kaneshiro T, Takeishi Y. Electrophysiological properties and involvement of anatomical factors for the prediction of intramural origin in patients with ventricular tachyarrhythmia arising from the left ventricular outflow tract. J Interv Card Electrophysiol 2021; 63:115-123. [PMID: 33564988 DOI: 10.1007/s10840-021-00959-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To elucidate the electrophysiological predictors of the intramural origins of left ventricular outflow tract-ventricular tachyarrhythmias (LVOT-VAs), and to clarify the involvement of anatomical factors. METHODS Twenty-nine successfully ablated LVOT-VAs patients with origins in the aortomitral continuity (AMC) (n = 8), aortic sinus of valsalva (ASV) (n = 9), great cardiac vein (GCV) (n = 5), and intramural myocardium (n = 7) were enrolled. Intramural origins were defined as when effective ablation from AMC and epicardium (ASV and/or GCV) was needed. The local activation time difference (LATD) was calculated as follows: (earliest AMC activation) - (earliest epicardial activation), and was presented as an absolute value. Electrophysiological parameters and anatomical factors predisposing the intramural origins were investigated. RESULTS LATD of intramural origins was significantly shorter than that of AMC and GCV (4.5 ± 2.6 vs. 12.1 ± 7.4 vs. 17.4 ± 4.7, P < 0.05), respectively. In multivariate logistic regression analysis, LATD was associated with intramural origins (odds ratio: 0.711, confidence interval: 0.514-0.985, P = 0.040). ROC analysis revealed LATD of 7 ms as cut-off value. In computed tomography analysis, some patients who had thick fat tissue below the GCV, and an unusual GCV running pattern might be misdiagnosed as intramural origins. CONCLUSION LATD ≤ 7 ms was associated with intramural origins, but with some anatomical limitations.
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Affiliation(s)
- Masashi Kamioka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan.
| | - Naoko Hijioka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Minoru Nodera
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shinya Yamada
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takashi Kaneshiro
- Department of Arrhythmia and Cardiac Pacing, Fukushima Medical University, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
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Noninvasive 3D Mapping and Ablation of Epicardial Premature Ventricular Contractions From the Endocardial Aspect of the Left Atrial Appendage. JACC Case Rep 2020; 2:1776-1780. [PMID: 34317055 PMCID: PMC8312108 DOI: 10.1016/j.jaccas.2020.07.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/07/2020] [Accepted: 07/22/2020] [Indexed: 01/21/2023]
Abstract
Ablation is an established treatment for ectopy originating from the left ventricle (LV). We report on a case of noninvasive 3-dimensional mapping locating the origin precisely in the epicardial LV summit area. However, after failed attempts from LV and epicardially, ablation via the left atrial appendage was finally successful. (Level of Difficulty: Advanced.)
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Kuniewicz M, Krupiński M, Gosnell M, Budnicka K, Jakob N, Karkowski G, Urbańczyk-Zawadzka M, Lelakowski J, Walocha J. Applicability of computed tomography preoperative assessment of the LAA in LV summit ablations. J Interv Card Electrophysiol 2020; 61:357-363. [PMID: 32666410 PMCID: PMC8324620 DOI: 10.1007/s10840-020-00817-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/29/2020] [Indexed: 11/12/2022]
Abstract
Purpose Ventricular arrhythmias originating from the left ventricular summit (LVS) may present with challenges for catheter ablation. Recently, the left atrial appendage (LAA) became a new vantage point for mapping and ablating arrhythmias from that region, but data of possible usefulness is limited. Methods From September to December 2019, we retrospectively analyzed 48 consecutive patient hearts (20 male; mean age 57.9y ± 11.56) undergoing diagnostic coronary vessel imaging in 64 dual-source computer tomography angiography (CTA). Distances from the LAA to the LVS, LAA shape type, and coronary arteries in the LVS region were measured. Also, we compared the true LVS area from CTA with a calculated formula derived from LVS definition. Results The mean LVS area calculated from the formula was 291.58 mm2 (± 115.5) while the true area calculated from CT was 263.33 mm2 (± 99.49) (p = 0.44). The mean inaccessible area was 133.42 mm2 (± 72.89), accessible 95.67 mm2 (± 72.77). The mean LAA coverage over LVS was 196.08 mm2—which is approximately 75% of LVS size in general. The most common LAA shape was chicken wing (50%); windsock has the highest accessible area coverage on average (80.23%), followed by chicken wing (59.88%), broccoli (47.72%), and cactus (46.98%). The mean distance from LAA to the surface was 5.14 mm (1.5 to 10 mm) and was not correlated with BMI. LAA has a 98% coverage over the point of transition between the great cardiac vein and anterior interventricular vein. Conclusion Angio-CT assessment of the LAA over the LVS structures may be helpful in decision making before an ablation procedure. LAA appears to be a promising mapping approach in LVS arrhythmias.
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Affiliation(s)
- Marcin Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland. .,Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland.
| | - M Krupiński
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - G Karkowski
- Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - M Urbańczyk-Zawadzka
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - J Lelakowski
- Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
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Kodali S, Santangeli P, Garcia FC. Mapping and Ablation of Arrhythmias from Uncommon Sites (Aortic Cusp, Pulmonary Artery, and Left Ventricular Summit). Card Electrophysiol Clin 2019; 11:665-674. [PMID: 31706473 DOI: 10.1016/j.ccep.2019.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite advances in our understanding of the relevant anatomy and mapping and catheter ablation techniques of idiopathic outflow tract ventricular arrhythmias, challenging sites for catheter ablation remain the aortic cusps, pulmonary artery, and notably the left ventricular summit. A systematic approach should be used to direct mapping efforts efficiently between endocardial, coronary venous, and epicardial sites. Foci at the left ventricular summit, particularly intraseptal and at the inaccessible epicardial region, remain difficult to reach and when percutaneous techniques fail, surgical ablation remains an option but with risk of late coronary artery stenosis.
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Affiliation(s)
- Santhisri Kodali
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA
| | - Fermin C Garcia
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA.
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Liang JJ, Shirai Y, Lin A, Dixit S. Idiopathic Outflow Tract Ventricular Arrhythmia Ablation: Pearls and Pitfalls. Arrhythm Electrophysiol Rev 2019; 8:116-121. [PMID: 31114686 PMCID: PMC6528030 DOI: 10.15420/aer.2019.6.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Idiopathic outflow tract ventricular arrhythmias (VAs) occur typically in patients without structural heart disease. They are often symptomatic and can sometimes lead to left ventricular systolic dysfunction. Both activation and pace mapping are utilised for successful ablation of these arrhythmias. Pace mapping is particularly helpful when the VA is infrequent and/or cannot be elucidated during the ablation procedure. VAs originating from different sites in the outflow tract region have distinct QRS patterns on the 12-lead ECG and careful analysis of the latter can help predict the site of origin of these arrhythmias. Successful ablation of these VAs requires understanding of the detailed anatomy of the OT region, which can be accomplished through electroanatomic mapping tools and intracardiac echocardiography.
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Affiliation(s)
- Jackson J Liang
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania Philadelphia PA, US
| | - Yasuhiro Shirai
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania Philadelphia PA, US
| | - Aung Lin
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania Philadelphia PA, US
| | - Sanjay Dixit
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania Philadelphia PA, US
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Okabe T, Rushing GD, Kalbfleisch SJ. Surgical Mapping and Ablation in the Left Ventricular Summit Guided by Presurgery Pericardial Mapping. J Innov Card Rhythm Manag 2019; 10:3582-3587. [PMID: 32477721 PMCID: PMC7252787 DOI: 10.19102/icrm.2019.100306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/16/2018] [Indexed: 11/29/2022] Open
Abstract
Successful catheter ablation of ventricular arrhythmias arising from the left ventricular (LV) summit is challenging. The use of a catheter-based epicardial approach may be limited due to the proximity of the major coronary arteries and the presence of epicardial fat. Surgical cryoablation in the LV summit is a viable option for drug-refractory ventricular arrhythmias. Presurgical epicardial mapping can facilitate the surgical procedure by localizing the area of interest to allow for a more limited surgical dissection of the epicardial fat.
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Affiliation(s)
- Toshimasa Okabe
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gregory D Rushing
- Division of Cardiothoracic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Steven J Kalbfleisch
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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