Catheter Ablation of Idiopathic Epicardial Ventricular Arrhythmias Originating from the Vicinity of the Coronary Sinus System

Abstract

Catheter Ablation of Idiopathic Epicardial Ventricular Arrhythmias. Idiopathic epicardial ventricular arrhythmias (IEVAs) originating from the vicinity of the coronary sinus system are not uncommon, accounting for about 9% of idiopathic ventricular arrhythmia cases. IEVAs share clinical presentation and electrophysiological characteristics with ventricular arrhythmias arising from the right ventricular outflow tract possibly as manifestations of cAMP-mediated triggered activity and delayed after-depolarizations. Detailed analysis of standard 12-lead electrocardiogram morphology by using unique variables and algorithms allows clinicians to predict probable location of epicardial foci and informs optimal catheter ablation strategy. Epicardial mapping and ablation through the coronary sinus and its branches is effective and safe, and increasingly favored. However, it is important because of the common perivascular origin of IEVAs to perform coronary angiography prior to or after ablation and to select the appropriate ablation energy form to avoid serious complications.

Morphometric Characterization of Human Coronary Veins and Subvenous Epicardial Adipose Tissue—Implications for Cardiac Resynchronization Therapy Leads

“…In contrast to the coronary arteries, the CVS is rather part of the problem solving than of the problem in most clinical cases. Besides catheter ablation of faulty conductive tissue (18) and mitral annuloplasty (19,20), the implantation of leads for cardiac resynchronization therapy (CRT) is one of the most relevant percutaneous interventions using the CVS. In German hospitals alone, more than 12,000 CRT systems for left ventricular arrhythmia therapy are implanted each year; this represents 12% of all annual cardiac implantable electronic devices and the number is rising (21,22).…”

2019 APHRS expert consensus statement on three‐dimensional mapping systems for tachycardia developed in collaboration with HRS, EHRA, and LAHRS

“…They are increasingly ablated from within the coronary venous with high success and low complication rates. 259 In summary, ablation of idiopathic OT-VT or OT-PVC can be ablated with a high success rate. Using 3D mapping systems allows to perform these procedures without fluoroscopy.…”

“…Left‐sided OT‐VT arising from the aortic cusps, aortomitral continuity, or LVOT can also be ablated with a high success rate but it mandates a retrograde aortic or sometimes transseptal or epicardial approach and are therefore a class IIa, level B indication for catheter ablation . Ablation procedure should be performed in experienced centers .…”

“…Up to 9% of idiopathic VA arise from the ventricular epicardium from the vicinity of the coronary sinus system. They are increasingly ablated from within the coronary venous with high success and low complication rates …”

“…Left-sided OT-VT arising from the aortic cusps, aortomitral continuity, or LVOT can also be ablated with a high success rate but it mandates a retrograde aortic or sometimes transseptal or epicardial approach and are therefore a class IIa, level B indication for catheter ablation. [256][257][258][259] Ablation procedure should be performed in experienced centers. 249 Since target foci may be ablated from the RVOT, LVOT, aortic cusps, left ventricle, or epicardially through the coronary sinus or even after a pericardial puncture, precise knowledge of the anatomy is paramount and 3D mapping plays their full potential.…”