Aortic sinuses of Valsalva as anatomic vantage point to ablate PVC from the LV summit: the role of intracardiac echocardiography
Pablo J Sánchez-Millán, Guillermo Gutiérrez Ballesteros, Miguel Álvarez. Hospital Universitario Virgen de las Nieves, Granada. Spain.
45-year-old male without previous structural heart disease presented with frequent symptomatic drug-refractory premature ventricular complexes (PVC) and mild left ventricular dysfunction related to PVC burden. The suspected site of origin according to the morphology of the ECG is the left ventricular summit (Figure 1).
The anatomic 3D reconstruction of the heart chambers was made using intracardiac echocardiography (ICE) and integrated in the navigation system using CARTOSOUND® module. A 3D-ICE map was performed, allowing visualization of the heart base/fibrous skeleton of the heart and rest of anatomic structures (Video 1).
After mapping the right ventricular outflow tract (RVOT), left ventricular outflow tract (LVOT) and distal coronary sinus, the earliest activation site was found in the aortic sinuses of Valsalva or aortic cusps, specifically in the junction between the left and right sinus of Valsalva, also called the left coronary cusp (LCC) and the right coronary cusp (RCC) (Figure 2).
The ostium of coronary arteries, with their anatomic outlets of their respective sinuses of Valsalva, were delineated with ICE and integrated in the map. Without using fluoroscopy, a safety distance to the ostium of the coronary arteries was confirmed (Figure 3) and radiofrequency (RF) ablation was performed between the junction of LCC and RCC (Video 2).
The application at that point suppressed the PVC focus with no acute recurrence after a waiting period and during patient follow up (Figure 4)
Sánchez-Millán PJ, Gutiérrez-Ballesteros G et al. Ablation with zero-fluoroscopy of premature ventricular complexes from aortic sinus cusps: A single-center experience. J Arrhythm. 2021 Oct 3;37(6):1497-1505