Successful catheter ablation of focal atrial tachycardia from the non-coronary aortic cusp

Atrial tachycardias arising from the atrial appendages and aortic sinus of valsalva

Focal atrial tachycardias arising from the atrial appendages and the aortic sinuses of Valsalva are less frequently encountered in clinical practice. This review article describes the clinical presentation, surface P wave morphology, electrophysiologic characteristics and treatment of these arrhythmias. Catheter ablation of these focal tachycardias has a high success rate. It is however important to be aware of specific anatomic considerations in these locations for optimal treatment outcomes with low complication rates.

Successful ablation of frequent atrial premature beats from non-coronary aortic cusp with remote magnetic navigation

A 59-year-old female with structurally normal heart was admitted to our hospital for treatment of highly symptomatic, drug refractory atrial premature beats (APB). ECG revealed atrial parasystolic trigeminy. The arrhythmogenic focus was mapped and ablated using magnetic remote navigation and 3D electroanatomical mapping system. To our knowledge, this is the first report on successful ablation of frequent APBs in the non-coronary aortic cusp.

Electroanatomic mapping-guided radiofrequency ablation of adenosine sensitive incessant focal atrial tachycardia originating from the non-coronary aortic cusp in a child

Incessant focal atrial tachycardia may be encountered in the pediatric age group although it is rarely seen. Ablation using radiofrequency or cryothermal energy is the preferred method for drug-resistant cases. Recently, 3D electroanatomic mapping systems have been increasingly used for mapping and ablation. In this report, we presented, for the first time, a pediatric case with incessant focal atrial tachycardia originating from the non-coronary aortic sinus and ablated using 3D electroanatomic mapping system.

Prevalence, risk, and benefits of radiofrequency catheter ablation at the aortic cusp for the treatment of mid- to anteroseptal supra-ventricular tachyarrhythmias

BACKGROUND

Some outflow tract ventricular tachycardias (VTs) are known to be successfully ablated from the aortic cusp (AC). However, radiofrequency catheter ablation (RFCA) at the AC for the treatment of supraventricular tachyarrhythmia (SVT) has limited experience.

METHODS

We performed RFCA at the AC in 19 patients (male 64.7%, 46.9 ± 21.9 years old) with mid- to anteroseptal SVTs (12 atrial tachycardias [AT], 7 atrioventricular reciprocating tachycardia [AVRT]), and analyzed the prevalence, electrophysiologic findings, clinical outcome, and compilation risk.

RESULTS

1. Among 113 patients with AT, 13 patients had mid- to anteroseptal AT and 12 patients (8.8%, 53.4 ± 19.8 years old, 58.3% female) underwent successful ablation from the non-coronary cusp (NCC; n=10), right CC (RCC; n=1) or left CC (LCC; n=1) without complication (3.1 ± 2.3 times RF delivery, 6.15 ± 3.08 s for termination). During 19.7 ± 9.8 months of follow-up, AT recurred in a patient with multiple foci. 2. Among 580 patients with AVRT, 27 patients had a mid- to anteroseptal bypass tract (4.7%), and 7 of them (1.1%, 2 pre-excitation syndrome, 5 concealed bypass tract) were successfully ablated at the NCC (n=2) or RCC (n=5) (7.0 ± 7.1 times RF delivery, 9.1 ± 4.4s for termination). Among 5 patients with AVRT successfully ablated at the RCC, one patient developed complete heart block 48 h after procedure, and 2 patients recurred AVRT or delta-wave in ECG during 13.9 ± 11.7 month follow-up.

CONCLUSION

Catheter ablation within the AC is an effective procedure to eliminate mid- to anteroseptal SVTs. However, RFCA on RCC requires a caution for heart block in our limited experience.

Atrial tachycardia initiating atrial fibrillation successfully ablated in the non-coronary cusp of the aorta

A 60-year-old woman was referred for catheter ablation of atrial fibrillation (AF). Atrial flutter and atrial tachycardia (AT) also had been clinically documented. During the electrophysiological study, the clinical AT was induced by burst atrial pacing during isoproterenol infusion and exhibited negative P waves in the inferior leads, positive P waves in leads I, aVL, and aVR, and biphasic P waves in lead V1. The AT repeatedly and spontaneously accelerated to initiate AF by causing fibrillatory conduction in the atria. Successful catheter ablation of the AT was achieved in the non-coronary cusp of the aorta (NCC) where the local atrio-ventricular electrogram amplitude ratio was >1 during both the AT and sinus rhythm. The tailored approach targeting the NCC AT alone without left atrial ablation completely eliminated the AF. In catheter ablation of AF in a patient with a co-existing clinical AT, it may be recommended to examine the clinical AT first. If the clinical AT initiates the AF and local atrial activations in the His bundle region precede the P wave onset during AT, mapping in the NCC should be considered prior to left atrial catheterization.

Catheter ablation within the sinus of Valsalva--a safe and effective approach for treatment of atrial and ventricular tachycardias

BACKGROUND

Ablation of the aortic sinus of Valsalva in adults for ectopic atrial tachycardia (EAT) and ventricular tachycardia (VT)/premature ventricular complexes (PVCs) has been reported in only a very few patients. Limited data exist concerning the safety of aortic ablation.

OBJECTIVE

The purpose of this study was to confirm aortic wall and aortic valve integrity after ablation and to evaluate for potential cerebral embolism due to thrombus formation at aortic wall lesions.

METHODS

From January 2006 to August 2007, 21 patients with EAT (n = 6) or VT/PVCs (n = 15) originating from the sinus of Valsalva underwent successful ablation. The aortic wall structure was evaluated using transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) the day after ablation and at 6-month follow-up for all patients. To rule out cerebral embolism due to postablation thromboembolic events, a cerebral MRI was performed immediately after ablation in six patients and at 6-month follow-up in all patients. Ablation success was defined by 24-hour Holter monitoring before hospital discharge and after 6 months.

RESULTS

Aortic wall integrity was confirmed in all patients by TEE and MRI. Cerebral MRI showed evidence of silent cerebral ischemia in one patient. Aortic valve thickening was detected in one patient by TEE.

CONCLUSION

Ablation in the aortic sinus of Valsalva is a safe and effective approach for atrial tachycardia or VT/PVCs. The incidence of silent ischemia needs further evaluation.

Successful ablation of atrial tachycardia in the right coronary cusp of the aortic valve in a patient with atrial fibrillation: what is the substrate?

Atrial tachycardias have been successfully ablated from the noncoronary cusp of the aortic valve. The anatomical substrate responsible for the arrhythmia in these patients is unknown. We report a case of intracardiac ultrasound confirmed ablation in the right coronary cusp of the aortic valve. Pacing maneuvers performed in this case, along with the regional anatomy of the right coronary cusp, strongly suggest that the ablated substrate is muscular extensions above the aortic valve. Ablation in the right coronary cusp eliminated tachycardia without valve damage or AV conduction abnormality.