A Comprehensive Review of Left Ventricular Summit Ventricular Arrhythmias
-
Farzad Kamali
,
Majid Haghjoo
,
Yeganeh Pasebani
,
Abolfath Alizadehdiz
,
Zahra Emkanjoo
,
Amirfarjam Fazelifar
,
Farzad Masoudkabir
,
Ala Keykhavani
,
Shabnam Madadi
Abstract
The catheter ablation of idiopathic ventricular arrhythmias is accepted as a first-line treatment as it successfully eliminates about 90.0% of such arrhythmias. One of the most challenging ventricular arrhythmias originates from the left ventricular summit (LVS), a triangular epicardial space with the left main bifurcation as its apex. This area accounts for about 14.0% of LV arrhythmias.
The complex anatomy of this region, accompanied by proximity to the major epicardial coronary arteries and the presence of a thick fat pad in this region, renders it a challenging area for catheter ablation.
This article presents a review of the anatomy of the LVS and relevant regions and discusses novel mapping and ablation techniques for eliminating LVS ventricular arrhythmias. Additionally, we elaborate on the electrocardiographic (ECG) manifestations of arrhythmias from the LVS and their successful ablation via the direct approach and the adjacent structures.
1. Kuniewicz M, Baszko A, Ali D, Karkowski G, Loukas M, Walocha JA, Hołda MK. Left Ventricular Summit-Concept, Anatomical Structure and Clinical Significance. Diagnostics (Basel) 2021;11:1423.
2. 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.
3. Ortale JR, Gabriel EA, Iost C, Márquez CQ. The anatomy of the coronary sinus and its tributaries. Surg Radiol Anat 2001;23:15-21.
4. Enriquez A, Malavassi F, Saenz LC, Supple G, Santangeli P, Marchlinski FE, Garcia FC. How to map and ablate left ventricular summit arrhythmias. Heart Rhythm 2017;14:141-148.
5. Lin CY, Chung FP, Lin YJ, Chong E, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chang YT, Chen YY, Chen CK, Chiou CW, Chen SA, Tsao HM. Radiofrequency catheter ablation of ventricular arrhythmias originating from the continuum between the aortic sinus of Valsalva and the left ventricular summit: Electrocardiographic characteristics and correlative anatomy. Heart Rhythm 2016;13:111-121.
6. Santangeli P, Marchlinski FE, Zado ES, Benhayon D, Hutchinson MD, Lin D, Frankel DS, Riley MP, Supple GE, Garcia FC, Bala R, Desjardins B, Callans DJ, Dixit S. Percutaneous epicardial ablation of ventricular arrhythmias arising from the left ventricular summit: outcomes and electrocardiogram correlates of success. Circ Arrhythm Electrophysiol 2015;8:337-343.
7. Tung R, Shivkumar K. Epicardial Ablation of Ventricular Tachycardia. Methodist Debakey Cardiovasc J 2015;11:129-134.
8. Bazan V, Gerstenfeld EP, Garcia FC, Bala R, Rivas N, Dixit S, Zado E, Callans DJ, Marchlinski FE. Site-specific twelve-lead ECG features to identify an epicardial origin for left ventricular tachycardia in the absence of myocardial infarction. Heart Rhythm 2007;4:1403-1410.
9. Yokoyama K, Nakagawa H, Shah DC, Lambert H, Leo G, Aeby N, Ikeda A, Pitha JV, Sharma T, Lazzara R, Jackman WM. Novel contact force sensor incorporated in irrigated radiofrequency ablation catheter predicts lesion size and incidence of steam pop and thrombus. Circ Arrhythm Electrophysiol 2008 ;1:354-362.
10. Sosa E, Scanavacca M, d'Avila A, Pilleggi F. A new technique to perform epicardial mapping in the electrophysiology laboratory. J Cardiovasc Electrophysiol 1996;7:531-536.
11. Di Biase L, Al-Ahamad A, Santangeli P, Hsia HH, Sanchez J, Bai R, Bailey S, Horton R, Gallinghouse GJ, Burkhardt DJ, Lakkireddy D, Yang Y, Badhwar N, Scheinman M, Tung R, Dello Russo A, Pelargonio G, Casella M, Tomassoni G, Shivkumar K, Natale A. Safety and outcomes of cryoablation for ventricular tachyarrhythmias: results from a multicenter experience. Heart Rhythm 2011;8:968-974.
12. Kreidieh B, Rodríguez-Mañero M, Schurmann P, Ibarra-Cortez SH, Dave AS, Valderrábano M. Retrograde Coronary Venous Ethanol Infusion for Ablation of Refractory Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2016;9:10.1161/CIRCEP.116.004352 e004352.
13. Tavares L, Lador A, Fuentes S, Da-Wariboko A, Blaszyk K, Malaczynska-Rajpold K, Papiashvili G, Korolev S, Peichl P, Kautzner J, Webber M, Hooks D, Rodríguez-Mañero M, Di Toro D, Labadet C, Sasaki T, Okishige K, Patel A, Schurmann PA, Dave AS, Rami TG, Valderrábano M. Intramural Venous Ethanol Infusion for Refractory Ventricular Arrhythmias: Outcomes of a Multicenter Experience. JACC Clin Electrophysiol 2020;6:1420-1431.
14. Yakubov A, Salayev O, Hamrayev R, Sultankhonov S. A case of successful ablation of ventricular tachycardia focus in the left ventricular summit through the left atrial appendage: a case report. Eur Heart J Case Rep 2018;2:yty110.
15. Sosa E, Scanavacca M, d'Avila A. Catheter ablation of the left ventricular outflow tract tachycardia from the left atrium. J Interv Card Electrophysiol 2002;7:61-65.
16. Futyma P, Moroka K, Derndorfer M, Kollias G, Martinek M, Pürerfellner H. Left pulmonary cusp ablation of refractory ventricular arrhythmia originating from the inaccessible summit. Europace 2019;21:1253.
17. Dong X, Sun Q, Tang M, Zhang S. Catheter ablation of ventricular arrhythmias originating from the junction of the pulmonary sinus cusp via a nonreversed U curve approach. Heart Rhythm 2019;16:1513-1520.
18. Dong X, Tang M, Sun Q, Zhang S. Usefulness of Reversed U-Curve Technique to EnhanceMapping and Ablation Efficiency in the Treatment ofPulmonary Sinus Cusp-Derived Ventricular Arrhythmias. Am J Cardiol 2018;122:814-820.
19. Teh AW, Reddy VY, Koruth JS, Miller MA, Choudry S, D'Avila A, Dukkipati SR. Bipolar radiofrequency catheter ablation for refractory ventricular outflow tract arrhythmias. J Cardiovasc Electrophysiol 2014;25:1093-1099.
20. Pandian J, Nandhakumar V, Saravanan S. Radiofrequency ablation of deep seated outflow tract ventricular tachycardia using custom modified bipolar irrigated radiofrequency ablation setup. Indian Pacing Electrophysiol J 2019;19:197-201.
21. Koruth JS, Dukkipati S, Miller MA, Neuzil P, d'Avila A, Reddy VY. Bipolar irrigated radiofrequency ablation: a therapeutic option for refractory intramural atrial and ventricular tachycardia circuits. Heart Rhythm 2012;9:1932-1941.
22. Nguyen DT, Olson M, Zheng L, Barham W, Moss JD, Sauer WH. Effect of Irrigant Characteristics on Lesion Formation After Radiofrequency Energy Delivery Using Ablation Catheters with Actively Cooled Tips. J Cardiovasc Electrophysiol 2015;26:792-798.
23. Nguyen DT, Gerstenfeld EP, Tzou WS, Jurgens PT, Zheng L, Schuller J, Zipse M, Sauer WH. Radiofrequency Ablation Using an Open Irrigated Electrode Cooled With Half-Normal Saline. JACC Clin Electrophysiol 2017;3:1103-1110.
24. Nguyen DT, Tzou WS, Sandhu A, Gianni C, Anter E, Tung R, Valderrábano M, Hranitzky P, Soeijma K, Saenz L, Garcia FC, Tedrow UB, Miller JM, Gerstenfeld EP, Burkhardt JD, Natale A, Sauer WH. Prospective Multicenter Experience With Cooled Radiofrequency Ablation Using High Impedance Irrigant to Target Deep Myocardial Substrate Refractory to Standard Ablation. JACC Clin Electrophysiol 2018;4:1176-1185.
25. Stevenson WG, Tedrow UB, Reddy V, AbdelWahab A, Dukkipati S, John RM, Fujii A, Schaeffer B, Tanigawa S, Elsokkari I, Koruth J, Nakamura T, Naniwadekar A, Ghidoli D, Pellegrini C, Sapp JL. Infusion Needle Radiofrequency Ablation for Treatment of Refractory Ventricular Arrhythmias. J Am Coll Cardiol 2019;73:1413-1425.
26. Atienza F, Arenal Á, Pérez-David E, Elízaga J, Ortuño JE, Ledesma-Carbayo MJ, Sánchez-Quintana D, Fernández-Avilés F. New diagnostic and therapeutic approaches to treat ventricular tachycardias originating at the summit of the left ventricle: role of merged hemodynamic-MRI and alternative ablation sources. Circ Arrhythm Electrophysiol 2013;6:e80-84.
27. Lampert SM, Michaud GF, Couper GS, Muehlschlegel JD. Epicardial cryoablation resulting in precipitous left ventricular dysfunction. J Thorac Cardiovasc Surg 2013;145:e41-e42.
28. Choi EK, Nagashima K, Lin KY, Kumar S, Barbhaiya CR, Baldinger SH, Reichlin T, Michaud GF, Couper GS, Stevenson WG, John RM. Surgical cryoablation for ventricular tachyarrhythmia arising from the left ventricular outflow tract region. Heart Rhythm 2015;12:1128-1136.
29. Okabe T, Rushing GD, Kalbfleisch SJ. Surgical Mapping and Ablation in the Left Ventricular Summit Guided by Presurgery Pericardial Mapping. J Innov Card Rhythm Manag 2019;10:3582-3587.
30. Fenelon G, Brugada P. Delayed effects of radiofrequency energy: mechanisms and clinical implications. Pacing Clin Electrophysiol 1996;19(4 Pt 1):484-489.
31. Nath S, Whayne JG, Kaul S, Goodman NC, Jayaweera AR, Haines DE. Effects of radiofrequency catheter ablation on regional myocardial blood flow. Possible mechanism for late electrophysiological outcome. Circulation 1994;89:2667-2672.
2. 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.
3. Ortale JR, Gabriel EA, Iost C, Márquez CQ. The anatomy of the coronary sinus and its tributaries. Surg Radiol Anat 2001;23:15-21.
4. Enriquez A, Malavassi F, Saenz LC, Supple G, Santangeli P, Marchlinski FE, Garcia FC. How to map and ablate left ventricular summit arrhythmias. Heart Rhythm 2017;14:141-148.
5. Lin CY, Chung FP, Lin YJ, Chong E, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chang YT, Chen YY, Chen CK, Chiou CW, Chen SA, Tsao HM. Radiofrequency catheter ablation of ventricular arrhythmias originating from the continuum between the aortic sinus of Valsalva and the left ventricular summit: Electrocardiographic characteristics and correlative anatomy. Heart Rhythm 2016;13:111-121.
6. Santangeli P, Marchlinski FE, Zado ES, Benhayon D, Hutchinson MD, Lin D, Frankel DS, Riley MP, Supple GE, Garcia FC, Bala R, Desjardins B, Callans DJ, Dixit S. Percutaneous epicardial ablation of ventricular arrhythmias arising from the left ventricular summit: outcomes and electrocardiogram correlates of success. Circ Arrhythm Electrophysiol 2015;8:337-343.
7. Tung R, Shivkumar K. Epicardial Ablation of Ventricular Tachycardia. Methodist Debakey Cardiovasc J 2015;11:129-134.
8. Bazan V, Gerstenfeld EP, Garcia FC, Bala R, Rivas N, Dixit S, Zado E, Callans DJ, Marchlinski FE. Site-specific twelve-lead ECG features to identify an epicardial origin for left ventricular tachycardia in the absence of myocardial infarction. Heart Rhythm 2007;4:1403-1410.
9. Yokoyama K, Nakagawa H, Shah DC, Lambert H, Leo G, Aeby N, Ikeda A, Pitha JV, Sharma T, Lazzara R, Jackman WM. Novel contact force sensor incorporated in irrigated radiofrequency ablation catheter predicts lesion size and incidence of steam pop and thrombus. Circ Arrhythm Electrophysiol 2008 ;1:354-362.
10. Sosa E, Scanavacca M, d'Avila A, Pilleggi F. A new technique to perform epicardial mapping in the electrophysiology laboratory. J Cardiovasc Electrophysiol 1996;7:531-536.
11. Di Biase L, Al-Ahamad A, Santangeli P, Hsia HH, Sanchez J, Bai R, Bailey S, Horton R, Gallinghouse GJ, Burkhardt DJ, Lakkireddy D, Yang Y, Badhwar N, Scheinman M, Tung R, Dello Russo A, Pelargonio G, Casella M, Tomassoni G, Shivkumar K, Natale A. Safety and outcomes of cryoablation for ventricular tachyarrhythmias: results from a multicenter experience. Heart Rhythm 2011;8:968-974.
12. Kreidieh B, Rodríguez-Mañero M, Schurmann P, Ibarra-Cortez SH, Dave AS, Valderrábano M. Retrograde Coronary Venous Ethanol Infusion for Ablation of Refractory Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2016;9:10.1161/CIRCEP.116.004352 e004352.
13. Tavares L, Lador A, Fuentes S, Da-Wariboko A, Blaszyk K, Malaczynska-Rajpold K, Papiashvili G, Korolev S, Peichl P, Kautzner J, Webber M, Hooks D, Rodríguez-Mañero M, Di Toro D, Labadet C, Sasaki T, Okishige K, Patel A, Schurmann PA, Dave AS, Rami TG, Valderrábano M. Intramural Venous Ethanol Infusion for Refractory Ventricular Arrhythmias: Outcomes of a Multicenter Experience. JACC Clin Electrophysiol 2020;6:1420-1431.
14. Yakubov A, Salayev O, Hamrayev R, Sultankhonov S. A case of successful ablation of ventricular tachycardia focus in the left ventricular summit through the left atrial appendage: a case report. Eur Heart J Case Rep 2018;2:yty110.
15. Sosa E, Scanavacca M, d'Avila A. Catheter ablation of the left ventricular outflow tract tachycardia from the left atrium. J Interv Card Electrophysiol 2002;7:61-65.
16. Futyma P, Moroka K, Derndorfer M, Kollias G, Martinek M, Pürerfellner H. Left pulmonary cusp ablation of refractory ventricular arrhythmia originating from the inaccessible summit. Europace 2019;21:1253.
17. Dong X, Sun Q, Tang M, Zhang S. Catheter ablation of ventricular arrhythmias originating from the junction of the pulmonary sinus cusp via a nonreversed U curve approach. Heart Rhythm 2019;16:1513-1520.
18. Dong X, Tang M, Sun Q, Zhang S. Usefulness of Reversed U-Curve Technique to EnhanceMapping and Ablation Efficiency in the Treatment ofPulmonary Sinus Cusp-Derived Ventricular Arrhythmias. Am J Cardiol 2018;122:814-820.
19. Teh AW, Reddy VY, Koruth JS, Miller MA, Choudry S, D'Avila A, Dukkipati SR. Bipolar radiofrequency catheter ablation for refractory ventricular outflow tract arrhythmias. J Cardiovasc Electrophysiol 2014;25:1093-1099.
20. Pandian J, Nandhakumar V, Saravanan S. Radiofrequency ablation of deep seated outflow tract ventricular tachycardia using custom modified bipolar irrigated radiofrequency ablation setup. Indian Pacing Electrophysiol J 2019;19:197-201.
21. Koruth JS, Dukkipati S, Miller MA, Neuzil P, d'Avila A, Reddy VY. Bipolar irrigated radiofrequency ablation: a therapeutic option for refractory intramural atrial and ventricular tachycardia circuits. Heart Rhythm 2012;9:1932-1941.
22. Nguyen DT, Olson M, Zheng L, Barham W, Moss JD, Sauer WH. Effect of Irrigant Characteristics on Lesion Formation After Radiofrequency Energy Delivery Using Ablation Catheters with Actively Cooled Tips. J Cardiovasc Electrophysiol 2015;26:792-798.
23. Nguyen DT, Gerstenfeld EP, Tzou WS, Jurgens PT, Zheng L, Schuller J, Zipse M, Sauer WH. Radiofrequency Ablation Using an Open Irrigated Electrode Cooled With Half-Normal Saline. JACC Clin Electrophysiol 2017;3:1103-1110.
24. Nguyen DT, Tzou WS, Sandhu A, Gianni C, Anter E, Tung R, Valderrábano M, Hranitzky P, Soeijma K, Saenz L, Garcia FC, Tedrow UB, Miller JM, Gerstenfeld EP, Burkhardt JD, Natale A, Sauer WH. Prospective Multicenter Experience With Cooled Radiofrequency Ablation Using High Impedance Irrigant to Target Deep Myocardial Substrate Refractory to Standard Ablation. JACC Clin Electrophysiol 2018;4:1176-1185.
25. Stevenson WG, Tedrow UB, Reddy V, AbdelWahab A, Dukkipati S, John RM, Fujii A, Schaeffer B, Tanigawa S, Elsokkari I, Koruth J, Nakamura T, Naniwadekar A, Ghidoli D, Pellegrini C, Sapp JL. Infusion Needle Radiofrequency Ablation for Treatment of Refractory Ventricular Arrhythmias. J Am Coll Cardiol 2019;73:1413-1425.
26. Atienza F, Arenal Á, Pérez-David E, Elízaga J, Ortuño JE, Ledesma-Carbayo MJ, Sánchez-Quintana D, Fernández-Avilés F. New diagnostic and therapeutic approaches to treat ventricular tachycardias originating at the summit of the left ventricle: role of merged hemodynamic-MRI and alternative ablation sources. Circ Arrhythm Electrophysiol 2013;6:e80-84.
27. Lampert SM, Michaud GF, Couper GS, Muehlschlegel JD. Epicardial cryoablation resulting in precipitous left ventricular dysfunction. J Thorac Cardiovasc Surg 2013;145:e41-e42.
28. Choi EK, Nagashima K, Lin KY, Kumar S, Barbhaiya CR, Baldinger SH, Reichlin T, Michaud GF, Couper GS, Stevenson WG, John RM. Surgical cryoablation for ventricular tachyarrhythmia arising from the left ventricular outflow tract region. Heart Rhythm 2015;12:1128-1136.
29. Okabe T, Rushing GD, Kalbfleisch SJ. Surgical Mapping and Ablation in the Left Ventricular Summit Guided by Presurgery Pericardial Mapping. J Innov Card Rhythm Manag 2019;10:3582-3587.
30. Fenelon G, Brugada P. Delayed effects of radiofrequency energy: mechanisms and clinical implications. Pacing Clin Electrophysiol 1996;19(4 Pt 1):484-489.
31. Nath S, Whayne JG, Kaul S, Goodman NC, Jayaweera AR, Haines DE. Effects of radiofrequency catheter ablation on regional myocardial blood flow. Possible mechanism for late electrophysiological outcome. Circulation 1994;89:2667-2672.
| Files | ||
| Issue | Vol 17 No 3 (2022): J Teh Univ Heart Ctr | |
| Section | Review Article(s) | |
| DOI | https://doi.org/10.18502/jthc.v17i3.10841 | |
| Keywords | ||
| Heart ventricle summit Ventricular premature complexes Tachycardia Ventricular Ablation techniques | ||
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How to Cite
1.
Kamali F, Haghjoo M, Pasebani Y, Alizadehdiz A, Emkanjoo Z, Fazelifar A, Masoudkabir F, Keykhavani A, Madadi S. A Comprehensive Review of Left Ventricular Summit Ventricular Arrhythmias. J Tehran Heart Cent. 2022;17(3):91-102.
