Successful Radiofrequency Catheter Ablation of an Anteroseptal (Superoparaseptal) Atrioventricular Accessory Pathway From the Left Ventricular Outflow Tract

A rare case of permanent junctional reciprocating tachycardia ablated on the roof of the left atrium

Left-sided anteroseptal accessory pathways that course through the aortomitral fibrous continuity are some of the rarest types of accessory pathways. At this region the atrium and ventricle are separated by their greatest distance because of the intervening aortic valve. These pathways often have a long circuitous course that may involve the root and cusps of the aortic valve. Prior reports have demonstrated the feasibility of ablating these pathways along the anteroseptal mitral annulus, the left ventricular outflow tract, or in the left or noncoronary cusps of the aortic valve. We describe a case of a concealed decremental anteroseptal accessory pathway that was ablated on the roof of the left atrium remote from the mitral or aortic valve annuli. This report indicates that when an appropriate site for ablation of a left-sided anteroseptal accessory pathway is not found close to a valve annulus, these pathways may be amenable to ablation by targeting their atrial insertion site.

Correlative anatomy for the invasive electrophysiologist: outflow tract and supravalvar arrhythmia

Radiofrequency ablation in the outflow tract and great arteries is increasingly performed to treat a variety of symptomatic cardiac arrhythmias. The regional anatomy of these structures is among the most complex of those encountered by cardiac electrophysiologists. An exact appreciation of the relationships between these overlapping structures and their proximity to the coronary arterial and conduction system is essential for rational, safe, and effective ablation for these arrhythmias. A supravalvar portion of the aorta is a unique site for arrhythmia origin where the arrhythmogenic substrate for atrial arrhythmias, ventricular arrhythmias, and accessory pathways may all be located. Discussed in this review are the main principles of outflow tract and supravalvar arrhythmia, and these are correlated with fluoroscopy, electrograms, and electrocardiography that help guide the invasive electrophysiologist.

An unusual case of permanent junctional reciprocating tachycardia: Successful ablation at the mitral annulus-aorta junction

A 25-year-old woman with drug-refractory permanent junctional reciprocating tachycardia (PJRT) and a previous failed ablation, was referred to our institution. Electrophysiological study confirmed the diagnosis of orthodromic atrioventricular reentry tachycardia using a slowly conducting accessory pathway. This accessory pathway was successfully ablated by conventional radiofrequency at the left anteroseptal region using a transseptal approach. Catheter ablation of this accessory pathway (Coumel type) at the mitral annulus-aorta junction offers insights on a rare anatomical location of PJRT.