Ventricular arrhythmias near the distal great cardiac vein: challenging arrhythmia for ablation

DOI: 10.1161/CIRCEP.114.001615

1

Ventricular Arrhythmias near the Distal Great Cardiac Vein:

A Challenging Arrhythmia for Ablation

Running title: Nagashima et al.; Ventricular arrhythmias near the GCV

Koichi Nagashima, MD, PhD; Eue-Keun Choi, MD, PhD; Kaity Y. Lin, MD; Saurabh Kumar,

MD, PhD; Usha B. Tedrow, MD, MSc; Bruce A. Koplan, MD, MPH; Gregory F. Michaud, MD;

Roy M. John, MD, PhD; Laurence M. Epstein, MD; Michifumi Tokuda, MD, PhD;

Keiichi Inada, MD, PhD; Gregory S. Couper, MD; William G. Stevenson, MD

Arrhythmia Unit, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA

Correspondence:

William G. Stevenson, MD

Cardiovascular Division

Brigham and Women’s Hospital

75 Francis St.

Boston, MA 02115

Tel: 1-857-307-1948

Fax: 1-857-307-1944

E-mail: [email protected]

Journal Subject Codes: [106] Electrophysiology, [22] Ablation/ICD/surgery

GrGrGrGregegegegorororory y y y F.F.F.F. MMMMicicicichahahahaudududud

i Tokkududududa,a,a,a, MMMMD,D,D,D, PPPPhDhDhDhD;

K

h M

Keeeeiiiiiichchchi Inaddddaa, MD, PhD; Greggggory yy S. Coupperr, MD;;;; Willllililiam G. Stevenson,, MD

hmiaaa UUUniniit,t,, CCCararardididiovovovasasascucuculalalalar r DiD vivvisisiooon,n,n,, BBBriiiighghghghamamam aaandndnd WWWomomomennen’sss HHHososospipipipitatatal,lll BBBososostotton,nn M

by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from

http://circep.ahajournals.org/












DOI: 10.1161/CIRCEP.114.001615

2

Abstract:

Background - Catheter ablation (CA) for ventricular arrhythmia (VA) near the distal great

cardiac vein (GCV) is often challenging and data are limited.

Methods and Results - Analysis was performed of 30 patients (19 male; age 52.8±15.5 years)

who underwent CA for focal VA (11 ventricular tachycardia, 19 premature contractions) with

early activation in the GCV (36.7±8.0 ms pre-QRS). Angiography in 27 patients showed earliest

GCV site within 5 mm of a coronary artery in 20 (74%). Ablation was performed in the GCV in

15 patients and abolished VA in 8. Ablation was attempted at adjacent non-GCV sites in 19

patients and abolished VA in 5 patients (4 from the left ventricular endocardium and 1 from the

the GCV (GCV-nonGCV interval). In 13 patients percutaneous epicardial mapping was

performed, but due to adjacent coronaries only 2 received radiofrequency application with VA

elimination in 1. Surgical cryoablation was performed in 3 patients and abolished VA in 2.

Overall acute success was achieved in 16 (53%) patients. After a median of 2.8 months, 13

patients remained free of VA. Major complications occurred in 4 patients including coronary

injury requiring stenting.

Conclusions - Ablation for this arrhythmia is challenging and often limited by the adjacent

coronary vessels. Success of anatomically guided endocardial ablation may be identified by a

short GCV-nonGCV interval and r wave in lead I.

Key words: ventricular arrhythmia, catheter ablation, great cardiac vein

rdial mamamamappppppppinininng g g g wawawawassss

but due to adjacent coronaries only 2 received radiofrequency application with

n in 1. Surgical cryoablation was performed in 3 patients and abolished VA in 2

u 3

mained free of VA. Major complications occurred in 4 patients including corona

u

n y g g y e adjacent

butututut ddddueuue ttttooo adddjajajacent coronaries only 2 recececeieived radiofreeequenenenency application with

n innnn 1. Surgicacacal crrryoyoyoyoabababa lalalaatitititionnnn wwwwaaas perrfooormmed innn n 3333 papapap tiiienenentts aaandnd aaaabobobobolilililishshshhedededed VVVA AAA ininini 2

uttteee sususuccessss wawaw s achihhievedededd iiiin 1616166 ((5333%)%)%)% pppatieientssss. AAAfA tter a medidiannnn ooof fff 2.8888 mommonnthsss, 13

maineneneed freeeeee of VAVAVA. Majjajjororoor complpp icatatattioii nsnsnns ooooccurrerered in 4 pppatatata ients inininincludududu ing gg corona

uiringgg stentinii g.g.g.

nnss - AbAblalatititit onon fffforor ttthihihih s ss ararrhrhhhyttythmhhmhmiaia iiiiss chchchhallallellel ngnginiini g g annnand dd d ofofffteten n lilililimiimiitettet d d dd bybbyb tttthhhhe e adadjajacecentnt

by guest on June 21, 2016http://circep.ahajournals.org/Downloaded from


DOI: 10.1161/CIRCEP.114.001615

3

Introduction

Catheter ablation (CA) for ventricular arrhythmia (VA) is a widely accepted therapy for patients

without structural heart disease, but the approach and outcomes depend on the site of arrhythmia

origin.1 Most VAs originate from the right or left ventricular outflow regions, including

myocardium around the aortic cusps and the summit of the left ventricle (LV). Approaches to

ablation of VA from specific areas are being increasingly refined. Ablation of VA originating

from near the distal great cardiac vein (GCV) is often difficult due to proximity to coronary

arteries limited capability of radiofrequency (RF) energy application in the GCV itself.2-5 We

have targeted these arrhythmias from various approaches including the endocardial, epicardial

via the GCV and pericardial space, and also with open chest surgery. The aim of this study was

to evaluate the mapping features, outcomes and risks for ablation of these VAs.

Methods

Patient characteristics

Of 270 patients (133 male, 49.2±14.0 years) without structural heart disease who underwent CA

for focal VA from January 2006 to January 2014, 30 patients (19 male, age 52.8±15.5 years)

with VA [11 with ventricular tachycardia (VT) and 19 with premature ventricular contractions

(PVC)] for which the earliest activation site before pericardial mapping was in the GCV were

analyzed. In 25 patients there was no evidence of structural heart disease. One patient had a

history of anthracycline chemotherapy and later developed cardiomyopathy. The remaining 4

patients had a history of LV dysfunction felt to be PVC induced. Each patient gave written

informed consent. Studies and data collection were performed according to protocols approved

by the Human Research Committee of Brigham and Women’s Hospital.

n the GCV itself.2 55 W

e endododd cacardddrdiiiaiallll, eepipiipicacacacardrd

V y

a

V aaaandndndd pperererericicicicarrrdidididial space, and also with opopopenn chest surgeegery. TTTThe aim of this study

tttht eee e mapping feeatuuurees, ouououtcommesss aandd rrriskks forrr aablblbllatatationnn of theheseee VVVAs..

araracacteteriristststiciici ss



DOI: 10.1161/CIRCEP.114.001615

4

Electrophysiological study and mapping

Procedures were performed either under conscious sedation or general anesthesia. Using

femoral venous and/or arterial access multipolar electrode catheters were positioned in the

coronary sinus to GCV, the right ventricular (RV) apex and the His bundle region. For the

patients with a history of sustained VT, programmed ventricular stimulation was performed with

up to 3 extrastimuli scanned to a minimum coupling interval of 180 ms following basic drives of

600 ms and 400 ms from 2 RV sites and burst pacing. If sustained VT was not reliably

inducible, non-sustained VT or PVCs felt likely to be originating from the same site, were

targeted. Intravenous infusion of isoproterenol and/or epinephrine was administered as needed

for arrhythmia induction.

Mapping and ablation was performed using a 3.5-mm-tip catheter (NaviStar ThermoCool

or ThermoCool SF; Biosense Webster, Diamond Bar, CA, USA) in 25 patients. In 5 patients a

4-mm-tip non-irrigated catheter (NaviStar, Biosense Webster) was used initially for mapping (5

patients) and attempted ablation (3 patients) before switching to an irrigated tip catheter.

Activation mapping of VT or PVCs utilized an electroanatomic mapping system (CARTO 3 or

XP, Biosense Webster) with bipolar electrograms high pass filtered at 20 to 30 Hz and low pass

filtered at 400 Hz. Bipolar electrograms were also band pass filtered from 30 to 500 Hz and

digitally recorded along with a 12-lead surface electrocardiogram (Cardiolab EP system, General

Electric Healthcare, Buckinghamshire, UK). Pace mapping utilized unipolar stimuli at 10 mA

and pulse width of 2 ms.6

Epicardial mapping was considered if a subepicardial VT origin was suspected based on

endocardial and GCV mapping, either at the same or a subsequent session. Percutaneous

subxiphoid epicardial access was obtained as previously described either before administration

m the same site, wwerererereeee

s admmininii isiiisttetet reredddd asas nnnneeee

m

p

Cool SF; Biosense Webster, Diamond Bar, CA, USA) in 25 patients. In 5 patien

n n

nd attempted ablation (3 patients) before s itching to an irrigated tip catheter

miaiaia iiiindndndnducucucctitititionnn. .. .

pppppiiiing and ablatationnn wwas pppep rforormedd ussinnng aa 3.5-555 mmmmmmmm--tippp cccathhetterrr (NNaN viviiiSStS arar TTheeermrmm

Coolll l SFSFSF;;;; BBBiosense WWWWebstttererere , Diammmmononono dddd BBaBB r,r, CCCCA,AAA UUUUSASASASA) ))) inininin 2222555 patiienenenentstststs. In 555 patititien

non-iiri iirigagg tedd d cacacaathhhheter (((NaNN viiiSStS ar, BiBiBiosense WWWW bbeb tster) ) ) waasss s usedededd iiinitiiialllllylyly fffforrrr mmmmapapapa pipp n

dd tattte ttedd babllatiti ((33 titi tts)) bbeffo iittchihi tt ii iig tat ded ttiip tathhette



DOI: 10.1161/CIRCEP.114.001615

5

of systemic anticoagulation or after anticoagulation was reversed.7

Ablation

Coronary angiography was performed prior to initial ablation at sites with the possibility of an

adjacent artery. If the distance of the catheter tip to a major coronary artery was < 4-5 mm, RF

delivery was avoided. RF application was also not attempted if there was diaphragmatic capture

during pacing from the ablation catheter. Irrigated RF energy was delivered at 25 to 50 Watts

targeting an impedance drop of 10 to 20 ohms. At endocardial sites below the aortic valve

applications were usually repeated until unipolar pacing at 10 mA at 2 ms stimulus strength

failed to capture.6 At target areas in the sinuses of Valsalva and GCV power exceeding 35 Watts

was avoided. At some sites where RF ablation was limited or coronary artery proximity was of

concern, ablation with a 6-mm-tip cryocatheter (Cryocath Technologies, Montreal, Canada) was

attempted.

At the end of the procedure, the same induction protocol was repeated. Acute success

was defined as the absence of any target arrhythmia.

Data collection and follow-up

Data were collected from a centralized system containing records of all patients treated and

followed at Brigham and Women’s Hospital and all associated Partners Healthcare sites. These

records include emergency department visits, outpatient clinic visits, data recorded during

inpatient care as well as follow-up progress notes from referring physicians monitoring out-of-

area patients. Referring physicians were contacted for clinical follow-up if necessary. Procedure

success was defined as more than an 80% reduction in VA on 24-hour Holter monitoring or

resolution of symptoms with no VA in all electrocardiograms during follow-up.

ms stimulus strengngngngttht

powwerer eexcxceeeedidididingng 33335555

ed. At some sites where RF ablation was limited or coronary artery proximity wa

b a

the end of the procedure, the same induction protocol was repeated. Acute succe

d as the absence of an target arrh thmia

ed. AtAtAtAt ssomomommee siiitetetetes where RF ablation was ss lilililimmited or corrronarararryy yy artery proximity wa

blllal tttit on with a 6---mmmm-tip p p cccryocac thhheeter (CCCryoyocathththth TTTeceece hnnnooologiies, MMMMontrrrreaaal, CCannnaddda

the endd d offf thehehe pppprocedudd re, thhthhe same iii dndduc iition ppprotot collll wawww s reeepepepep tat ddedd. AAAcuuuutetetete ssssuuucu ce

dd tthhe bbs ff tta tet hh thth imi



DOI: 10.1161/CIRCEP.114.001615

6

Statistical Analysis

Continuous variables were expressed as mean±SD values or median and interquartile ranges

(IQR) are shown in parentheses, as appropriate. Student’s t-test or Mann-Whitney’s U test was

used to compare continuous variables, depending on whether the values were normally

distributed, and the chi-square test was used to compare dichotomous variables unless the

expected values in any cells were <5, in which case Fisher exact test was used. P<0.05 was

considered to be statistically significant. Statistical analyses were performed with JMP 9

software (SAS Institute, Cary, NC, USA).

Results

Electrophysiological characteristics

Patient and arrhythmia characteristics are shown in Tables 1. Examples of VA morphology are

shown in Supplemental figure 1. Sustained VT was inducible in 10 of 11 patients who had a

history of sustained VT. The lead V1 morphology was right bundle branch block-like in 21

(70%), and left bundle branch block morphology with precordial transition before V3 in 8 (27%)

and after V3 in 1 (3%). All VAs had an inferior axis (98.6±10.0°). QRS duration was

161.9±18.8 ms (Table 1). The maximum deflection index (MDI) defined as the interval from the

earliest QRS onset to the earliest R-wave peak in the precordial leads divided by the QRS

duration8 was greater than 0.55, suggesting epicardial origin, in 10 (33%) patients, with a mean

of 0.52±0.06. Prior ablation attempts had failed in 16 patients, 5 of whom had received RF

applications at the earliest RV sites at our institution.

Mapping and ablation in the GCV

Activation mapping revealed the earliest ventricular activation in the GCV preceded the QRS

onset by 36.7±8.0 ms (Figures 1B and 2B, and supplemental figure 2B). At this site a perfect

y

d arrhythmia characteristics are shown in Tables 1. Examples of VA morphology

Supplemental figure 1. Sustained VT was inducible in 10 of 11 patients who had

sustained VT. The lead V1 morphology was right bundle branch block-like in 21

yyyysiooolo ogical ccchhah raraaccctc ererererisisistititiiccsc

d arrrrhrhrhrhytytytythmhmhmmiaiaiia cccchahahararararactcctc ererere istititiicscscs aaaarerr ssshohohoh wnwnwnwn iiin n n n TaTaTaablblblblesesese 111.. EEEExaxaxax mpmpmpmplelelesss s ofofof VVVVA A A A momomomorprprphohohoholololoogyggg

Supplplplplemememenenentatatalll fifififiguguguurerere 111... SSSusussustatatainnnnededed VVVTT T T waaaas ss ininindudududuciciciciblblblbleee inininin 11110 000 ofofof 1111111 papapap tititiienenene tstsss wwwhohoho hhhhad

ssusustataineded VVVVT.T.TT ThThThThe e leleel adaddd VVV1111 mooorpphohohh lololol gygy wwasas rigiigi hthththt bbbbunu dldldldle e brbrbb ana chchhh bbbblollol ckkckk-l-likee in 21



DOI: 10.1161/CIRCEP.114.001615

7

pace-map, matching the VA in 12 of 12 ECG leads was present in 21 of 24 (88%) patients

(Figures 1A and 2A, and supplemental figure 2A). In the remaining 3 (12%) patients an 11 of 12

lead pace-map match was observed. In 3 patients pacing at the earliest GCV site failed to

capture the ventricular myocardium even with the strength of 10 mA and pulse width of 9 ms.

A flow chart indicating procedure details is shown in Supplemental figure 3. In 3

patients an ablation catheter could not be advanced to the distal GCV. Coronary venography and

angiography was performed in the remaining 27 patients. In 7 patients (23%) the target site in

successfully abolishing the VA in 5 patients (Figures 1C-E). In 8 of remaining 20 patients in

whom the target site in the distal GCV was <5mm from the coronary artery (Supplemental

figures 2C-D), ablation was attempted at a region 2-3 mm proximal to the target site with

elimination of VA in 3 patients. For all GCV RF ablation applications the average RF power

was 23 (IQR 15, 27) Watts and duration 30 (IQR 23, 39) seconds, limited by an impedance rise

that typically began after 15 to 20 seconds starting from a relatively high initial impedance of

244 (IQR 186, 266) ohms. In 4 patients cryoablation in GCV was attempted due to low power

and high impedance with failure of RF ablation in 3 patients and for reinforcement of an acutely

successful RF ablation in 1. Cryoapplication of -80 °C freezes was performed for 4-8 minutes

successfully abolishing the VA in 2 patients.

Characteristics of patients for whom radiofrequency energy was delivered in the GCV are

shown in Supplemental table. The surface ECG of the VA morphology including R-S in lead I,

R ratio in lead III/II and Q ratio in aVL/aVR suggested that the VA origin was more leftwards in

the patients with successful ablation in the GCV compared with patients in whom ablation in the

GCV failed. The MDI was greater in those with successful ablation. However, there were no

emainini inini gg 20202020 ppatatieieeentntntntss

t

-

n of VA in 3 patients. For all GCV RF ablation applications the average RF pow

QR 15, 27) Watts and duration 30 (IQR 23, 39) seconds, limited by an impedance

ll began after 15 to 20 seconds starting from a relati el high initial impedance

tarrgegegegetttt sisisis tetetee iiiinn thhhee ee distal GCV was <5mm frfrfrfroom the coronnnary ararara tery (Supplemental

-D)D)D)D), ablation wwaas aaatttttemptptptpted aattt t a reegiononn 2---3 mmmm pppprorror ximamm l too ttheeee tttargeeeet siss tte wittthhh

n off VVVVAAAA inininin 3 p ttatieiii ttnts. For r allalalllll GCCCCVVV V RFRFRFRF ablblbl tttatioii nnnn apapplplplpliicatatattiiions ttthehhh aaveveveverage RRRRF FFF pow

QQQR 1515151 , 272727))) WaWaWatttttttts andd d dudd ratiitiion 3333000 (I(I(IQRQRQRQ 2222333, 3339)9)9)9 secondddsd , llil mimimiteteteed ddd bybyby an impepepepedadadadance

llll bb ftft 1155 tto 2200 dnd tst titi ff llatiti ll hhiighh iinititiiall iim dda



DOI: 10.1161/CIRCEP.114.001615

8

differences in the RF power and duration, and initial impedance between the 2 groups.

Endocardial Ablation Outside the GCV

In all patients additional non-GCV mapping was performed before successful GCV ablation or

after GCV ablation failed; in the RV in all, and in the LV cavity and the aortic sinus in 26

patients respectively. RF was applied at the earliest RV site in 4 patients and failed to abolish

VA in all. In the LV and the aortic sinus the earliest ventricular activation preceded the surface

QRS onset by 20.9±6.6 ms and none had a perfect pace-map. (Figures 2A-B and supplemental

figures 2A-B). In 4 of 12 (33%) patients who had RF application below the aortic-mitral

continuity (AMC) and 1 of 5 (20%) patients who had RF application in left coronary cusp

(LCC), VA was successfully abolished despite later activation at these sites that in the GCV

(Figures 2C-D). Ablation failed at endocardial LV sites or the aortic sinus in 10 patients.

As shown in table 2, all patients with successful LV endocardial or LCC ablation had a

VA morphology with an initial r wave in lead I compared to 33% of patients with ablation failure

at these sites (P=0.01). Furthermore, patients with successful LV endocardial or LCC ablation

tended to have later activation times at the GCV (31.0±5.0 vs. 38.1±8.7 ms preceding surface

QRS, P=0.09) and the activation times at the earliest LV endocardial or LCC sites tended to be

earlier (25.8±4.0 vs. 19.6±6.6 ms preceding surface QRS, P=0.06) compared to patients with

ablation failure at these sites. Thus, the interval between the GCV site and earliest LV

endocardial or LCC site activation during the VA (GCV-nonGCV interval) was shorter for those

with successful endocardial ablation compared to those in whom ablation failed (5.8±1.6 vs.

18.9±8.5 ms, P=0.003; Table 2) and was -map

morphology for those with successful versus unsuccessful endocardial ablation.

Percutaneous Epicardial Ablation

ow the aortic-mitrralalalal

n lefffft ttt cocororonanaryryyy ccususususppp p

A V

C

shown in table 2, all patients with successful LV endocardial or LCC ablation ha

o

es (P 0 01) F rthermore patients ith s ccessf l LV endocardial or LCC ablat

A wawawawassss sussuccccccccesee sfffuuully abolished despite lateeer rr aactivation at thtt esssee e e sites that in the GCV

CCCC-DDD). Ablatioon faiiileed atttt eeendoco arrrddial LLLV ssittes ororrr tttthehheh aaaorrrtic siinunuus in 10 000 papap tiientttst ...

showwwwnnn ininnin tabbbblelll 2222, alllllll patiiienenenntsttsts withhh h sususucccces ffsful LLLLVVV V enenenendddod cacacaca ddrddiiiallll or LLLLCCCCCCCC ablblblb tttatioi n hhahh

ologggy yy wiiith hh annn iiiiniiiitiiialll r wave in llleaddd III I compppar dded to 333333%%% % fofof pppatatattiiiei tnts iwii hththh ablblblblatatatatiiioi n

((PP 00 0101)) FF trthhe tatiie tnt iithth ff ll LVLV dnd didi lal LCLCCC babllatt



DOI: 10.1161/CIRCEP.114.001615

9

Percutaneous epicardial mapping from the pericardial space was performed in 13 patients and

revealed sites where the earliest ventricular activation preceded onset of surface QRS by

29.1±6.3 ms (Supplemental figure 2B); and 2 patients had sites that were slightly earlier than that

of the GCV (by approximately 2 ms in both). At the earliest epicardial site, a perfect pace-map

was acquired in 2 of 10 patients despite slightly later activation (by approximately 2 ms) than the

GCV (Supplemental figure 2A). Coronary angiography was repeated during epicardial mapping

in 10 patients; no ablation was performed due to the proximity to a coronary artery in 8 (80%)

patients (Supplemental figure 2D). RF ablation was performed in 2 patients (20%) with

elimination of VA in 1 (10%). No cryoablation was performed.

Complications of catheter ablation

Major complication occurred in 3 patients. Coronary artery occlusion requiring stenting of a

marginal branch of the circumflex artery occurred in 2 who received average RF energies of 23

and 27 Watts at ablation sites felt to be 2 mm and 5-7 mm distant from the vessel, respectively.

GCV perforation without tamponade occurred in 1 patient.

Open-chest surgical epicardial ablation

In 3 patients who failed percutaneous catheter ablation, open-chest cryothermal surgical

epicardial ablation with direct vision through a median sternotomy was subsequently performed.

After dissection to reach the GCV area freezes performed under direct visualization successfully

abolished the VA in 2 patients. In the remaining patient ablation was limited due to the

vasospasm of the left anterior descendant (LAD) and difficulty fully dissecting the LAD.

Furthermore, angina developed several months after the procedure, angina and angiography

revealed a stenosis in the LAD at the site of cryoablation that was treated with a drug-eluting

stent.9

atients (2( 0%)) withhhh

t

m f

ranch of the circumflex artery occurred in 2 who received average RF energies o

t v

oration itho t tamponade occ rred in 1 patient

tionnnnssss ofofof ccccatatatheheeteteteter ablation

mppplp iccation occuurrreddd inn 3 pappp tienntttst . CCorroonarry artetetteryryryry occlululusionn rreqqquuiu ringggg sssteenntinggg of

ranchhh h ofofofof tttthhhe ciiircumfffflelll x arrrrtetetetery occcccuururu rerereddd d iniii 2222 whohohoho rrececececeiiiiveveveveddd d averaggeeee RFRFRRF energieiii s o

tts at babblatiiionnn ssssittes fff llelt to bbbbe 2 22 mm and 555-77 7 mm dddiiisi tantnt ffffrom mm ththththe vess llel, reeeespspspspeeece tiv

tatiio iithth tt tta dad ded ii 11 titi tt



DOI: 10.1161/CIRCEP.114.001615

10

Acute success and long term success during follow-up

Overall acute success was achieved in 16 (53%); 8 in GCV, 4 at AMC, 1 in LCC, 1 in

pericardium space and 2 with surgical ablation. In these patients 1 patient who had had incessant

VT before ablation procedure resumed low-dose amiodarone for 2 months.

After a median follow-up of 2.8 (0.9, 26.5) months in these 16 patients, procedure

success was evaluated by 24-hour Holter in 7 patients (2 with VT and 5 with PVCs), and clinical

symptom and electrocardiography in 9 (7 with symptomatic VTs and 2 with symptomatic

recurrent PVCs) patients. Thirteen patients (81%) were free of VA; VA recurred in 3 patients

(19%) which had been ablated in the GCV in 1, from the endocardium at the AMC in 1, and

from the pericardial space in 1.

Discussion

Catheter ablation of VA originating from near the GCV is often challenging. However, in 5 of 7

patients (71%), in whom RF application was effectively delivered in the GCV, VA was

successfully eliminated. During follow-up 88% of patients in whom VA was successfully

ablated in the GCV were free from VA recurrence. Therefore, acute and long-term success can

be favorable, if RF application can successfully be performed.2-5

Unfortunately, ablation is often not possible. In some cases it is not possible to advance

an ablation catheter to the distal GCV. Probably the most important risk when delivering RF

energy in the GCV is coronary artery injury. Coronary artery damage may be evident acutely or

may not become manifest until several weeks after the procedure.10, 11 The minimal safe distance

between ablation sites and coronary arteries is not clear. It is likely that tissue contact, power,

duration, and coronary blood flow all influence the risk. During angiography cardiac motion can

make the distance and time spent between the ablation catheter and coronary arteries difficult to

VA recurred in 3 ppatatatatieieii

m at thhhhe e AMAMAMAMCC CC iiinin 1111, aaanan

e

n

blation of VA originating from near the GCV is often challenging. However, in

1%), in whom RF application was effectively delivered in the GCV, VA was

ericacacacardrdrdrdiaiaiai llll spsspaccccee e e in 1.

n

blatioioioionn n ofofof VVVA AA ororoorigigigiginininatatatinining gg frfrfrfromomomm nnneaeaear rr thththt e GCGCGCG V V VV isisisi oooftftftf enenen ccchahahah llllllenenenngigigigingnngng. HHHHowowowweveveverererer,,, , in

1%)%),, in wwhohohoh m RFRFRFRF aappppplilililicacatitititiono wwwasas eeffffffffecectititit vevelyllyl ddddellelivivivivere eddedd iiin ththththee GCGCGCGCV,V,VV VVVVA AA A wawass



DOI: 10.1161/CIRCEP.114.001615

11

assess. Distances of 5 to 12 mm between the catheter tip and the coronary artery may be needed

to avoid any risk of injury.7

Inability to deliver sufficient RF energy due to high impedance and/or limited cooling

from surrounding blood flow likely contributes to limit the effectiveness of ablation in the GCV.

Cooling the saline infusion has been suggested,12 but was not assessed in this study. In the GCV,

impedance was typically high and began increasing further within 25 seconds of RF delivery. In

our experience attempted additional RF applications at the same site after an initial impedance

rise typically produce an even more rapid impedance rise. Occasionally the GCV is of sufficient

size to allow longer RF applications. More leftward VA origin in the patients with successful

ablation in the GCV might indicate that the origin in the GCV was relatively proximal where the

vessel size was sufficiently large to allow greater power. RF power was not, however,

statistically different between the patients with and without successful ablation in the GCV in

this small study. Cryoablation can be considered, as it is not limited by high impedance, and is

likely facilitated by low blood flow. Freezing also appears less likely to damage adjacent

coronary arteries.13 However, the cryocatheter can be difficult to maneuver in the coronary

venous system.

When ablation in the GCV was not feasible or failed, we attempted to ablate at the best

identifiable endocardial sites. In 20% of patients who underwent additional non-GCV mapping

including endocardial LV and the aortic sinus, RF application at the site closest to the early GCV

site successfully eliminated the VA despite later activation at these sites. Interestingly, in those

patients the GCV-nonGCV interval was shorter for successful endocardial LV or LCC ablation

sites compared to unsuccessful ablation at these sites. In all patients with successful endocardial

ablation the GCV-

ly y the GCV is of susususufff

patienenttsts wwitititithhh h susucccccesesesesss

e

y different between the patients with and without successful ablation in the GCV

study. Cryoablation can be considered, as it is not limited by high impedance, an

itated b lo blood flo Free ing also appears less likel to damage adjacent

the e ee GCGCGCG V VVV mimmm ghghghhtt t indicate that the origin iiiinn n tht e GCV waaas relalalal titt vely proximal whe

wawawawas sufficienttlyy laaargge ttto o o alloooww grggreateerrr poowwer. RFRFRFF ppowwwer wwaas nnnoot, hoooowwew vever,

y diffffffferereerennenenttt t betttween thhththe paatitititieenents witititithhhh anaa d ddd wiiiiththtt ououououttt t susususuccesesess ffsffulll ablbbb attttioioioionnn n in ttthhhe GGGGCVVCVCV

studydydyd . CCCryyyoablblbllattiiioi n can bbeb con iisidded red, as iiti iiis nott llil mimiteteeed dd bybybyy hhhhigigigi hhh iimii pepp dadadaancncncn eee,e an

itit tat ded bb llo blbl dd flfl FF iin lal ll lilikkell tt dda djdj tt



DOI: 10.1161/CIRCEP.114.001615

12

than at failed sites. A possible mechanism of the shorter GCV-nonGCV interval in the

successful endocardial ablation group is shown in Supplemental figure 4. Furthermore, all VA

successfully ablated from endocardial LV or LCC had an initial r wave in lead I. Hence, those 2

features suggest that VA origin might be located relatively closer to the endocardium and might

be predictors for the successful ablation from those sites. Pace-mapping at the LV endocardium

was not a reliable marker for successful ablation. These observations are similar to those of

Abularach and colleagues, who reported successful ablation from the LV endocardium from the

left sinus of Valsalva, LV endocardium, or both sites in 9 of 16 in a similar group of patients14.

Epicardial mapping was also limited in this patient population. Sedation and anesthesia

as is generally used for epicardial procedures can suppress arrhythmias, although we did not

encounter this as a significant issue in the present small series. The GCV area is often covered

by fat and the overlying left atrial appendage and coronary arteries are present. Further right-

ward from the GCV, the LV myocardium is beneath the RV outflow.5 In only 1 patient (8%) in

whom RF energy was delivered from the pericardial space, the VA was acutely abolished, but

later recurred during follow-up.

Open-chest surgical epicardial ablation successfully eliminated VA in 2 of 3 patients

(67%). A direct cardiac surgical approach can offer a potential solution for these VAs; deep

lesions can be achieved with surgical application of cryoablation, which achieves temperatures

-160°C) than those that can be achieved with present catheter

cryoablation, and coronary arteries can be avoided under direct vision or occasionally mobilized

for ablation of tissue beneath the vessel.15, 16 However, surgical morbidity is a concern.

Coronary injury is also possible. Mapping to identify the ablation target can be difficult in the

operating room andanesthesia can suppresses the arrhythmia.17

milar grg oupp of ppatatttieieieienn

Seddddatattioioii nn anandddd anannesesesesttthth

a o

this as a significant issue in the present small series. The GCV area is often cove

the overlying left atrial appendage and coronary arteries are present. Further righ

%

energ as deli ered from the pericardial space the VA as ac tel abolished b

ally y yy usuusu edededed fffforoo eeepipipicardial procedures can sususuppppress arrhythhmiasasasas, although we did no

thhhhissss as a signifficcanttt iiissuuue e in ttttheheheh ppprreseenttt smamall sssererrrieieieess. ThThThe GCGCV VV V aarea iiiis offteen cococove

the ovevevverlrllrlyiyingng lll ffefftt tt ttat iiirial apppppppeeendagegegee aa dndndnd coronararryyyy arrrteteteteriiiiesesess are preseeeentntntnt. Furthththher riiiigh

the GGGCVCVCV, thhhe ee LVLVLVLV myoyy ca drdddiiui m iiis bbbenea hhth thehhh RRRRVVV V ou ftftfflolooow.555 InInInIn onlly yy 111 papp tititit enenenenttt t (8(( %

dd lelii ded ff thth iri drdiiall tthhe VVAA tt lel bab loliishhedd bb



DOI: 10.1161/CIRCEP.114.001615

13

Limitations

This is a retrospective descriptive case series, with a relatively small number of patients.

Patients were referred for ablation and 16 had failed prior ablation attempts.

Conclusions

Catheter ablation for arrhythmias originating in the region of the distal great cardiac vein is

challenging with a favorable ablation outcome in only 53% in this referral population and likely

a greater risk of complications than expected for idiopathic VA. Although epicardial ablation is

often limited by the proximity of coronary vessels, anatomically guided endocardial ablation can

be successful and predicted by a relatively short GCV-nonGCV interval and r wave in lead I.

Surgical ablation can also be effective. Future studies to identify optimal strategies are

warranted.

Acknowledgments: Dr. Nagashima was supported in part by a Medtronic Japan Fellowship.

Conflict of Interest Disclosures: William Stevenson is co-holder of a patent for needle ablation

that is consigned to Brigham and Women’s Hospital.

References:

1. Sacher F, Tedrow UB, Field ME, Raymond JM, Koplan BA, Epstein LM, Stevenson WG. Ventricular tachycardia ablation: Evolution of patients and procedures over 8 years. Circ Arrhythm Electrophysiol. 2008;1:153-161.

2. Baman TS, Ilg KJ, Gupta SK, Good E, Chugh A, Jongnarangsin K, Pelosi F, Jr., Ebinger M, Crawford T, Oral H, Morady F, Bogun F. Mapping and ablation of epicardial idiopathic ventricular arrhythmias from within the coronary venous system. Circ Arrhythm Electrophysiol.2010;3:274-279.

3. Obel OA, d'Avila A, Neuzil P, Saad EB, Ruskin JN, Reddy VY. Ablation of left ventricular epicardial outflow tract tachycardia from the distal great cardiac vein. J Am Coll Cardiol.2006;48:1813-1817.

g p

ed d ennnndodododocacacacardrdrdrdiaiaiaial l l l abababablalalalatitiiioooo

ful and predicted by a relatively short GCV-nonGCV interval and r wave in lead

b

d i

ful annnddd prprpredidd cttttedeee by a relatively short GCVCVCV-nonGCV intervvvvalaaa and r wave in lead

bllllattttiiioi n can allllsososo be ee fefefeffefefef ctctctctivivivive. FuFuFuFututut re ssttuudiiess tooo o ididididenenene tifyfyfyf optptptimiimal sssstrtrtrattategegeggieeeesss arararare ee

dgments:::: DDDDr.r.r.r NNNNagagagagasasasashiihihimamamam wwwasasasas sssupupupuppopopoportrtrttedededed iiiin n nn papapapartrtrt bbby y y y a aa a MeeMeMedtdtdtdtrorororonininnic cc c JaJaJaJapapapapan nnn FeFFF llowshi



DOI: 10.1161/CIRCEP.114.001615

14

4. Steven D, Pott C, Bittner A, Sultan A, Wasmer K, Hoffmann BA, Kobe J, Drewitz I, Milberg P, Lueker J, Monnig G, Servatius H, Willems S, Eckardt L. Idiopathic ventricular outflow tract arrhythmias from the great cardiac vein: Challenges and risks of catheter ablation. Int J Cardiol.2013;169:366-370.

5. Yamada T, McElderry HT, Doppalapudi H, Okada T, Murakami Y, Yoshida Y, Yoshida N, Inden Y, Murohara T, Plumb VJ, Kay GN. Idiopathic ventricular arrhythmias originating from the left ventricular summit: Anatomic concepts relevant to ablation. Circ Arrhythm Electrophysiol. 2010;3:616-623.

6. Soejima K, Stevenson WG, Maisel WH, Sapp JL, Epstein LM. Electrically unexcitable scar mapping based on pacing threshold for identification of the reentry circuit isthmus: Feasibility for guiding ventricular tachycardia ablation. Circulation. 2002;106:1678-1683.

7. Sosa E, Scanavacca M, d'Avila A. Transthoracic epicardial catheter ablation to treat recurrent ventricular tachycardia. Curr Cardiol Rep. 2001;3:451-458.

8. Daniels DV, Lu YY, Morton JB, Santucci PA, Akar JG, Green A, Wilber DJ. Idiopathic epicardial left ventricular tachycardia originating remote from the sinus of valsalva: Electrophysiological characteristics, catheter ablation, and identification from the 12-lead electrocardiogram. Circulation. 2006;113:1659-1666.

9. Lampert SM, Michaud GF, Couper GS, Muehlschlegel JD. Epicardial cryoablation resulting in precipitous left ventricular dysfunction. J Thorac Cardiovasc Surg. 2013;145:e41-42.

10. Roberts-Thomson KC, Steven D, Seiler J, Inada K, Koplan BA, Tedrow UB, Epstein LM, Stevenson WG. Coronary artery injury due to catheter ablation in adults: Presentations and outcomes. Circulation. 2009;120:1465-1473.

11. Castano A, Crawford T, Yamazaki M, Avula UM, Kalifa J. Coronary artery pathophysiology after radiofrequency catheter ablation: Review and perspectives. Heart Rhythm. 2011;8:1975-1980.

12. Sternick EB, Gerken LM, Scarpelli RB, Soares FC. Cooling with near-freezing saline improves efficacy of cool-tip radiofrequency catheter ablation. Heart Rhythm. 2010;7:983-986.

13. Stavrakis S, Jackman WM, Nakagawa H, Sun Y, Xu Q, Beckman KJ, Lockwood D, Scherlag BJ, Lazzara R, Po SS. Risk of coronary artery injury with radiofrequency ablation and cryoablation of epicardial posteroseptal accessory pathways within the coronary venous system. Circ Arrhythm Electrophysiol. 2014;7:113-119.

14. Jauregui Abularach ME, Campos B, Park KM, Tschabrunn CM, Frankel DS, Park RE, Gerstenfeld EP, Mountantonakis S, Garcia FC, Dixit S, Tzou WS, Hutchinson MD, Lin D, Riley MP, Cooper JM, Bala R, Callans DJ, Marchlinski FE. Ablation of ventricular arrhythmias arising

abababablalalalatitititionononon tttto ooo trtrtrtreaeaeaeatttt rereeecucuuu

Dl

yd

t SM, Michaud GF, Couper GS, Muehlschlegel JD. Epicardial cryoablation resulo

s Thomson KC Ste en D Seiler J Inada K Koplan BA Tedro UB Epstein L

DV,V,V,V LLLLuuu YYYYYYY , MoMMM rton JB, Santucci PA, AkAkAkAkaar JG, Green A, WiWWW lber DJ. Idiopathic leeeeftftft ventriculululu ararar tttacchyhyhyycacacaardrdiaaaia oooorir gigiginananatiiingngng remmote e e frfrfrfromomomom tthehehehe sssininusususu of vavavavalslslslsalaa vavava:::

ysssis ooolo ogical chaaraactereeriiisticscscs, caththththettterr abblaaatioonn, andndndn iiidedded ntifififiiicatioion fffrf oom tttheheheh 1122-leadadad diogogogrraram. CiCiiircrrr uulaatiooonn. 200006060606;1131313:11116656 99-9 111666..

t SM,M,M,, MMMicicicchahahaudududud GGGF,F,F,F CCCCououououpepepeer r rr GSSSS,,, MuMuMuMueheehe lssschchchc leleleegegegegelll JDJDJDJ . EpEpEpEpiciccicararardidididialalall ccccryryryoaoaoaoablblblatatatatioioioonn n rerereresulous llleffft ventririricuccc lalll r dydydy ffsfun tction. J JJ ThThThhorac CCCardididiiovasc SuSuuurggg. 202020201313131 11;14545454 :e41414141-4-4-442.222

ThTh KCKC StSt DD SSeilil JJ IIn dad KK KK lla BABA TTeddr UUBB EE tteiin LL



DOI: 10.1161/CIRCEP.114.001615

15

near the anterior epicardial veins from the left sinus of valsalva region: Ecg features, anatomic distance, and outcome. Heart Rhythm. 2012;9:865-873.

15. Mulpuru SK, Feld GK, Madani M, Sawhney NS. A novel, minimally-invasive surgical approach for ablation of ventricular tachycardia originating near the proximal left anterior descending coronary artery. Circ Arrhythm Electrophysiol. 2012;5:e95-97.

16. Stevenson WG, Couper GS. A surgical option for ventricular tachycardia caused by nonischemic cardiomyopathy. Circ Arrhythm Electrophysiol. 2011;4:429-431.

17. Bhavani SS, Tchou P, Chung M, Fahmy T, Gillinov AM. Intraoperative electro-anatomical mapping and beating heart ablation of ventricular tachycardia. Ann Thorac Surg. 2006;82:1091-1093.



DOI: 10.1161/CIRCEP.114.001615

16

Table 1. Patient characteristics with VA close to the GCV

Values are the mean±SD, median (25th, 75th interquartile range) or n (%). VA, ventricular arrhythmia; GCV, great cardiac vein; LVEF, left ventricular ejection fraction; VT, ventricular tachycardia; RBBB, right bundle branch block; LBBB, left bundle branch block; MDI, maximum deflection index; RFA, radiofrequency ablation.

Patients(n=30)

Age (y) 52.8±15.5Male 19 (63)LVEF (%) 52.0±12.9History of prior ablation 16 (53)Clinical ArrhythmiasSustained VT 11 (37)Nonsustained VT or PVCs 19 (63)

VA morphology during EPSVT sustained 10 (33)Cycle length of VTs (ms) 396.2±81.8QRS width (ms) 161.9±18.8MDI 0.52±0.06QRS axis (°) 98.6±10.0Limb leadsQS pattern in lead I 16 (53)R-S in lead I (mV) -0.23±0.35R in lead II (mV) 1.78±0.59

R in lead III (mV) 1.97±0.61Ratio in III/II 1.12±0.16

R in aVF (mV) 1.87±0.59Q in aVL (mV) 1.12±0.38Q in aVR (mV) 0.85±0.36Ratio in aVL/aVR 1.46±0.60

Precordial leadsRBBB pattern 21 (70)LBBB with R- 8 (27)

MappingActivation time at GCV (ms) 36.7±8.0

12/12 pace map at GCV 21/24 (88)Ablation in GCVAverage power (Watts) 23 (15, 27)Average duration (seconds) 30 (23, 39)Initial impedance (ohms) 244 (186, 266)RFA + cryoablation 4 (13%)

sndI

I(mV) 1 87±0 59

°) 9989 ..6±10.0sn iin lead I 16 (53))))d I II (m(m(m( V)V)V) -00.0 2232 ±0±0±0±0.3.3.3.35555II (mVVVV) 1.1.1.78777 ±0.5999(mV)V)V)V) 1.1.1.97979797±0±0±0±0.6.6.661111

IIIIII/I/I/IIII 111.121212±0±0±0.1.1.1666(((mVmVmV))) 111.878787±0±0±0 55.5999



DOI: 10.1161/CIRCEP.114.001615

17

Table 2: Characteristics of patients who had ablation attempted at the left ventricular endocardium or aortic sinus according to acute outcome

Successful(n=5)

Failure(n=21) P value

Age (y) 59.0±8.1 53.8±15.9 0.50Male 4 (80) 13 (62) 0.63Successful siteAMC 4 (80) -LCC 1 (20) -

VA morphology during EPSVT sustained 2 (40) 7 (33) 1.00Cycle length of VTs (ms) 334.5±36.1 392.7±46.8 0.15QRS width (ms) 159.8±17.0 162.7±20.6 0.78MDI 0.51±0.06 0.51±0.06 0.92QRS axis (°) 94.2±12.8 98.8±9.4 0.36Limb leadsInitial r wave in lead I 5 (100) 7 (33) 0.01R-S in lead I (mV) -0.05±0.27 -0.23±0.36 0.30R in lead II (mV) 2.01±0.93 1.69±0.52 0.31

R in lead III (mV) 2.07±1.00 1.88±0.51 0.54Ratio in III/II 1.02±0.06 1.13±0.17 0.18R in aVF (mV) 1.98±1.02 1.80±0.50 0.56Q in aVL (mV) 1.01±0.52 1.10±0.37 0.67Q in aVR (mV) 0.96±0.46 0.83±0.35 0.47Ratio in aVL/aVR 1.07±0.22 1.47±0.57 0.14

Precordial leadsRBBB pattern 4 (80) 13 (62) 0.63LBBB with R-wave transition V3 5 (100) 20 (95) 1.00

MappingActivation time at GCV (ms) 31.0±5.0 38.1±8.7 0.09Activation time at the earliest endocardial site (ms) 25.8±4.0 19.6±6.6 0.06Interval between these 2 sites (ms) 5.8±1.6 18.9±8.5 0.00312/12 pace-map at GCV 3/3 (100) 17/19 (89) 1.00

12/12 pace-map at the earliest endocardial site 0/5 (0%) 0/13 (0%) 1.00

Values are the mean±SD or n (%). AMC, aortic-mitral continuity; LCC, left coronary cusp; other abbreviations are as in Table 1

92.7±46.8 0.15555666622.22 7777±±±±20202020.6.6.66 00.0.0 78787878.51±0.0.00 0606 0.0.0.0.9292929

) 94 2±12 8 98 8±9 4 0 36

adI

ImV) 1.98 1.02 1.80 0.50 0.56

) 94.2±12.8 9898998.8±9.4 0.36

avvve in lead I 5 (1(1(1( 000000)))) 77 7 (33)3)3)3 00.00 01111d I II (m(m(mV) -0...0500 ±±±0.2777 --000.23333±±±±0.36666 000.3000I (mVVVV))) 222.01001±0.0 9993 11.669±0.00 525252 00.3131(mV)V)V)V) 2.2.2.2 0707070 ±±±1.11 00000000 1.1.1.1 8888888 ±±±±0.0.0.5151515 0.00.0 5454544

IIII/I/III 11.0202±±00.0606 11.1313±±00.1717 00.1818mVmVmV))) 1.11 989898±±±1.11 020202 111.808080±±±00.0 505050 000.565656



DOI: 10.1161/CIRCEP.114.001615

18

Figure Legends:

Figure 1: An example of one patient with successful ablation of ventricular arrhythmia (VA) in

the great cardiac vein (GCV). (A) Twelve-lead electrocardiogram morphologies of sinus rhythm,

VA and pace-map morphologies recorded during electrophysiological study. A perfect pace-

map (12/12 leads) is acquired in the GCV. (B) The local electrogram of successful ablation site

in the GCV. (C) Corresponding fluoroscopic view of catheter positions during coronary

venography from contrast injection thorough the irrigated ablation catheter.2 The ablation

catheter tip is at the distal GCV. (D) Corresponding fluoroscopic view of catheter positions

distant from any coronary artery. (E) The surface electrocardiogram (top) and ablation catheter

electrogram (bottom) during radiofrequency delivery. Cessation of the target VA is observed

shortly after radiofrequency initiation.

SR, sinus rhythm; PVC, premature ventricular contraction; PM, pace-map; GCV, great cardiac

vein; V-QRS, the interval between ventricular electrogram and surface QRS; ABL-d, ablation

catheter distal; ABL-p, ablation catheter proximal; EA, the earliest activation; LAD, left anterior

descendant; AIV, anterior interventricular vein; LCX, left circumflex; RAO, right anterior

oblique; LAO, left anterior oblique; RF, radiofrequency.

Figure 2: Data from a patient in whom ventricular arrhythmia (VA) was successfully ablated

from the endocardium below the aortomitral continuity (AMC) region despite later activation at

that site than in the GCV. (A) Twelve-lead electrocardiogram morphologies of sinus rhythm, VA

and pace-map morphologies recorded during electrophysiological study. A perfect pace-map

heter.2 The ablattioioioion nnn

w of cacathththh tetetterer pposositittioioioionnnns

m h

m (bottom) during radiofrequency delivery. Cessation of the target VA is observ

e

rh thm; PVC premat re entric lar contraction; PM pace map; GCV great card

mmmm aaaanyn coronarry arttterry. (E(E(EE) Thhhhe sussurfacceee elecectrocoocararara diddid ogograraram ((toop)))) aand ababaa lall ttioon cccaaath

m (bbbotototottototom)m)m)m dduriiing g radiddd offreeeeququququencyyy ddddeleleliiivi ery.y CeCeCCesssssatatatioioioion ofofofo tttthehh ttttargegeeettt VAVVV iiis obbbbserv

er radididi foffrequqq enenenncyyy iiiniii iitiatioii n.

hrh tthhm PVPVCC tt ttriic ll ttr titi PMPM GGCVCV tt drd



DOI: 10.1161/CIRCEP.114.001615

19

(12/12 leads) is acquired in the GCV compared to poor pace-map at AMC. (B) The local

electrograms in the GCV and AMC. The earliest ventricular activation is obtained in the GCV.

(C) Activation map and the successful ablation site at the AMC. (D) The surface

electrocardiogram (top) and ablation catheter electrogram (bottom) during radiofrequency

delivery. Cessation of the target VA is observed shortly after radiofrequency initiation.

AMC, aortic-mitral continuity; LV, left ventricle; AV, aortic valve; CS, coronary sinus; other

abbreviations are as in Figure 1.



I

III

II

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

PM at GCV

SR

PVC

I

IIIII

ABL-d

ABL-p

V1

V5

(A) (B)

100 ms1 mV

V-QRS: 35ms

SR 100 ms

1 mV

VVVV-QQQQRRRRABL-dddd

AAAABBBBLLL-pppp



(D)

RAO LAO

LAD

LCX

EA site EA site

LCX

LAD

(C)

RAO LAO

AIV

AIV

GCV

GCV

EA site

EA site

5mm

5mm

A i

A

A i

AAAAOOOO LLLLAAAAOOOO



(E) 1 s

RF



I

III

II

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

PM at GCVPVC PM at AMC

(A)

SR 100 ms

1 mV



I

IIIII

ABL-d

ABL-p

V1

V5

GCV

AMC

I

IIIII

ABL-d

ABL-p

V1

V5

(B)

100 ms1 mV

V-QRS: 35ms

V-QRS: 28ms

I

GGGCCCCVVVV

III



(D)

(C)

1 s

RF

LAO

LV

CS

GCV

AV

LAOLLLAAAOOO

LLLVVV



Gregory S. Couper and William G. StevensonKoplan, Gregory F. Michaud, Roy M. John, Laurence M. Epstein, Michifumi Tokuda, Keiichi Inada,

Koichi Nagashima, Eue-Keun Choi, Kaity Y. Lin, Saurabh Kumar, Usha B. Tedrow, Bruce A.Ablation

Ventricular Arrhythmias near the Distal Great Cardiac Vein: A Challenging Arrhythmia for

Print ISSN: 1941-3149. Online ISSN: 1941-3084 Copyright © 2014 American Heart Association, Inc. All rights reserved.

Dallas, TX 75231is published by the American Heart Association, 7272 Greenville Avenue,Circulation: Arrhythmia and Electrophysiology

published online August 10, 2014;Circ Arrhythm Electrophysiol.

http://circep.ahajournals.org/content/early/2014/08/10/CIRCEP.114.001615World Wide Web at:

The online version of this article, along with updated information and services, is located on the

http://circep.ahajournals.org/content/suppl/2014/08/10/CIRCEP.114.001615.DC1.htmlData Supplement (unedited) at:

http://circep.ahajournals.org//subscriptions/

is online at: Circulation: Arrhythmia and Electrophysiology Information about subscribing to Subscriptions:

http://www.lww.com/reprints Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answerinformation about this process is available in the

requested is located, click Request Permissions in the middle column of the Web page under Services. FurtherCenter, not the Editorial Office. Once the online version of the published article for which permission is being

can be obtained via RightsLink, a service of the Copyright ClearanceCirculation: Arrhythmia and Electrophysiology Requests for permissions to reproduce figures, tables, or portions of articles originally published inPermissions:


http://circep.ahajournals.org/content/early/2014/08/10/CIRCEP.114.001615

http://circep.ahajournals.org/content/suppl/2014/08/10/CIRCEP.114.001615.DC1.html

http://www.ahajournals.org/site/rights/

http://www.lww.com/reprints

http://circep.ahajournals.org//subscriptions/


1

SUPPLEMENT MATERIAL Supplemental Table. Characteristics of patients for whom radiofrequency energy was delivered at the distal of great cardiac vein according to acute outcome

Successful

(n=8) Failure (n=7)

P value

Age (y) 44.4±18.6 54.3±10.2 0.23 Male 4 (50) 3 (43) 1.0 VA morphology during EPS VT sustained 6 (75) 2 (29) 0.13 Cycle length of VTs (ms) 423.2±102.8 349.5±57.2 0.39 QRS width (ms) 162.0±19.8 159.0±15.3 0.76 MDI 0.56±0.06 0.49±0.03 0.02 QRS axis (°) 102.7±6.1 94.5±12.1 0.14 Limb leads Initial r wave in lead I 4 (50) 4 (57) 1.00 R-S in lead I (mV) -0.35±0.22 0.02±0.39 0.08 R in lead II (mV) 1.60±0.60 1.85±0.64 0.46

R in lead III (mV) 1.87±0.72 1.84±0.53 0.92 Ratio in III/II 1.16±0.13 1.01±0.13 0.05 R in aVF (mV) 1.74±0.62 1.83±0.63 0.79 Q in aVL (mV) 1.07±0.43 0.93±0.26 0.49 Q in aVR (mV) 0.73±0.26 0.92±0.28 0.20 Ratio in aVL/aVR 1.49±0.47 1.03±0.21 0.04 Precordial leads RBBB pattern 7 (88) 3 (43) 0.12 LBBB with R-wave transition ≤ V3 7 (88) 7 (100) 1.00 Mapping Activation time at GCV (ms) 37.5±11.0 36.0±7.33 0.76

12/12 pace map at GCV 7/7 (86) 7/7 (86) 1.00 Ablation

Irrigated catheter 7 (88) 5 (71) 0.57 Average power (Watts) 24 (21, 31) 17 (9, 27) 0.41 Average duration (seconds) 30 (25, 56) 30 (18, 51) 0.78 Initial impedance (ohms) 240 (181, 414) 248 (190, 279) 1.00 RFA + cryoablation 3 (38) 1 (14) 0.57

2

Values are the mean±SD or n (%). VA, ventricular arrhythmia; GCV, great cardiac vein; LVEF, left ventricular ejection fraction; VT, ventricular tachycardia; RBBB, right bundle branch block; LBBB, left bundle branch block; MDI, maximum deflection index; RFA, radiofrequency ablation.

3

Supplemental figure legends

Supplemental Figure 1.

Examples of 12-lead electrocardiogram morphologies of VA. (A) Patients who had

successful ablation in the great cardiac vein (GCV). (B) Patients who failed ablation

in the GCV. (C) Patients who had successful ablation at the aortic-mitral continuity

(AMC).


An example from a patient in whom ablation of ventricular arrhythmia (VA) close to the

great cardiac vein (GCV) failed.

(A) Twelve-lead electrocardiogram morphologies of sinus rhythm, VA and pace-map

morphologies recorded during electrophysiological study. A perfect pace-map (12/12

leads) is acquired in the GCV and pericardium compared to poor pace-map at

aortic-mitral continuity (AMC)

(B) The local electrograms in the GCV, AMC and pericardium. Earliest ventricular

activation is obtained in the GCV.

(C) Corresponding fluoroscopic view of catheter positions during coronary venography

from contrast injection thorough the irrigated ablation catheter. The ablation catheter

tip is at the distal GCV.

(D) Corresponding fluoroscopic view of catheter positions during coronary angiography

of the left coronary artery. The earliest site in the GCV is 2mm distant from the left

anterior descending coronary artery, and the earliest site in the pericardium is adjacent

to the diagonal branch of the left anterior descendant.

AMC, aortic-mitral continuity; other abbreviations are as in Figure 1.

4


A flow chart indicating the procedure details and follow-up data in patients with

ventricular arrhythmias close to the distal great cardiac vein.

GCV, great cardiac vein; LCA, left coronary artery; RF, radiofreuency; RV, right

ventricle; Ao, aorta; LV, left ventricle; AMC, aortic-mitral continuity; LCC, left

coronary cusp.


A schematic diagram (A) and the ladder diagrams (B and C) explaining possible

mechanism of the GCV-nonGCV interval is shown. The GCV-nonGCV interval is

shorter in the successful endocardial ablation group (B) than the endocardial ablation

failure group (C). In the successful endocardial ablation group, VA origin might locate

relatively closer to the endocardium compared to failure group as the endocardial RF

lesion reached the origin. Therefore, that location might result in a shorter activation

time interval between the GCV and the earliest LV endocardial or LCC sites.

VA, ventricular arrhythmia; other abbreviations are as in Supplemental figure 3.

I

III

II

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

Supplemental figure 1

(A) (B) (C)

Successful ablation at AMC Ablation failure in GCV Successful ablation in GCV

I

III

II

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

PM at GCV PVC PM in pericardial space PM at AMC

(A)

SR 100 ms

1 mV


I

III

II

ABL-d

ABL-p

V1

V5

GCV

AMC

Pericardial space

I

III

II

ABL-d

ABL-p

V1

V5

I

III

II

ABL-d

ABL-p

V1

V5

(B)

100 ms 1 mV

V-QRS: 33ms

V-QRS: 15ms

V-QRS: 31ms

(C)

RAO LAO

EA site at pericardium

EA site in GCV

LAD

LCX

EA site at pericardium

(adjacent to Diagonal)

LAD

LCX

EA site in GCV (2mm to LAD)

Diagonal

Diagonal

(D)

AIV

AIV

GCV GCV EA site

EA site

RAO LAO

< 5mm to LCA

n=20

≥ 5mm to LCA

n=7

Ablation catheter could not

be advanced to the distal GCV.

n=3 GCV ablation

n=7

GCV mapping

n=30

Ao cusp or LV mapping

n=26

Epicardial mapping

n=13

RV mapping

n=30

AMC ablation

n=12

No coronary angiography

n=3

≥ 5mm to LCA

n=2

< 5mm to LCA

n=8

RV ablation

n=4

LCC ablation

n=5

Pericardial ablation

n=2

Non-GCV

mapping

No coronary angiography

n=3

Proximal GCV ablation

n=8

Acute success

n=3

Procedure success

n=3

Procedure success

n=1

Procedure success

n=0

Acute success

n=5

Acute success

n=0

Acute success

n=4

Acute success

n=1

Acute success

n=1

Open-chest

Surgical ablation

n=3

Procedure success

n=2

Acute success

n=2

Procedure success

n=4

Procedure success

n=3


(B) (C)

*

LV myocardium

Epicardium

Endocardium

GCV-nonGCV interval ≤ 7ms

*

GCV-nonGCV interval > 7ms

RF lesion

VA origin

VA origin

GCV

(A)

LV cavity

Successful endocardial ablation Endocardial ablation failure


Ventricular arrhythmias near the distal great cardiac vein: challenging arrhythmia for ablation

Documents

Transcript of Ventricular arrhythmias near the distal great cardiac vein: challenging arrhythmia for ablation