10/27/2013 Ablation of VT Originating from Left Coronary Sinus of Valsalva Ni Nine netee teen n yr yr-old old male pr male prese esente nted d wi with th rec ecur urren ent e t episo pisode des s of of r rapid pa pid palpit lpitati tion ons s of of 3 3 yea ear-du durati tion on, oc , occu curri ring ng at r t rest, est, incr increa easing sing i in n fr freq eque uenc ncy y wi with th exer ercise cise, , lasting lasting for f or few ew se seco cond nds s to se to sever eral m al minute inutes, s, so sometimes metimes ass assoc ocia iated ted w wit ith h dizzine dizziness an ss and d pr presy esync ncop ope. H e. He w e was as on on pr prop opran anolol olol 10 10 mg mg tds tds wi with th no no impr improveme ement. No histor nt. No history y of of rheuma rhe umati tic c fever er. . No FH of No FH of SCD SCD o or r simi similar lar cond co ndit itions ions. 1
10/27/2013 Gen Gener eral: al: BP BP = = 110 110/60 60, , HR HR = = 70 70/mi /min, of n, of a aver erage ge vol ol, , eq equa ual l on on both both si side des an s and d pe peri riph pher erall ally f y felt, elt, no no L LL L ed edema ema, , che hest w st was as clear lear. . pu pulse lse sh shows f ws freq eque uent nt full fully co y compe mpensa nsated ted extr xtrasy asystoles stoles (> (>10 10/mi /min). n). Car Cardiac diac: : Normal Nor mal S1, , S2, , no no ad additi dition onal al so soun unds o ds or r murmur mur murs. s. 2
10/27/2013 Echocardiography: Normal study EP study and ablation: ( Done 6 ms ago) Activation mapping showed a focus originating from LVOT. Results: Disappearance of VT and NSVT with and without induction, but PVCs persisted. One month later, patient developed recurrence of VT on 24 h Holter recording. Plan: For repeat ablation using CARTO Rep epea eat t EPS EPS Baseline ECG: Spontaneous frequent V ectopy and NSVT 3
10/27/2013 CARTO mapping AO LM LV Coronary angiogram 4
10/27/2013 Activation mapping PVC 25 ms Site of origin Lt guiding was used.. wire was placed in LM during ablation 5
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10/27/2013 Propagation map Pre ablation ECG Post ablation ECG 7
10/27/2013 Prevalence Is a variant of LVOT VT. Up to 18% of idiopathic VTs/PVCs. More likely to arise from the LC sinus than from the RC sinus and are rare in the NC sinus. Rarely may present as RVOT VT when myocardial bridging between RC sinus and RVOT with preferential conduction. Anatomic considerations The right and left coronary sinuses incorporate ventricular musculature at their base but the non-coronary sinus is exclusively composed of fibrous walls 8
10/27/2013 The hinge of the valvular leaflet is attached to the ventricular myocardium well proximal to the anatomic ventriculo- arterial junction Heart2000;84:670-673 doi:10.1136/heart.84.6.670 LVOT-VT: Supravalvular focus: Absent S in V5, V6 Infravalvular focus: S in V5, V6 Sensitivity 100% Specificity 88% V5 V6 Hachiya H , et al. . How to diagnose, locate, and ablate coronary cusp ventricular tachycardia. J Cardiovasc Electrophysiol 2002;13:551-6. 9
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