Reentrant para‐Hisian ventricular tachycardia eliminated from the noncoronary cusp: Importance of regional anatomy for vantage‐point ablation

Abstract

We present a rare case of reentrant ventricular tachycardia proven by entrainment maneuvers that was successfully ablated from the noncoronary cusp. The case highlights regional anatomy, pacing maneuvers with multi‐modality images from fluoroscopy, intracardiac echo, and electroanatomical mapping.

The noncoronary sinus of Valsalva: At the cusp of correlating anatomy, physiology, and ablation success

“…With re‐entrant arrhythmia, there is no real early or late activation since the entire cycle length of the tachycardia does have recordable activation at some portion of the myocardium 4 . Nishimura et al 1 report sites almost 70 ms earlier than the earliest discernible QRS deflection. Automatic tachycardias are rarely recorded locally more than 40 ms before the QRS and any signals encroaching late or mid‐diastole should alert the operator to the presence of re‐entry even when the heart is normal.…”

“…Although re‐entrant mapping can typically diagnose this mechanism for arrhythmia, here also some pitfalls need to be avoided. Nishimura et al, 1 demonstrate fusion during ventricular pacing of arrhythmia, which is highly suggestive of a re‐entrant ventricular tachycardia. However, triggered automatic tachycardias where the arrhythmia speeds up with ventricular pacing and produces fusion in addition to unusual variants of AV tachycardia such as antidromic nodal ventricular tachycardia, retroaortic AV nodal‐related tachycardia, and unusual forms of AV node re‐entry with upper common pathway block may all show fusion and reset with ventricular pacing.…”

“…Nishimura et al 1 provide an excellently illustrated and discussed case that gives JCE readers an opportunity to deepen their understanding of the local anatomy and physiology of the para‐Hisian region and in addition highlight pitfalls with mapping re‐entry and the rarely considered differential diagnosis of tachycardias unique to this crucial portion of the heart.…”

“…Of note, Nishimura et al, 1 describe their ablation being at the noncoronary cusp. They undoubtedly mean the depths of the NSOV since the aortic valve leaflets are rarely if ever the source of tachycardia but commonly considered synonymous with the sinuses of Valsalva themselves.…”

“…The directly posterior continuation of the membranous septum is the noncoronary sinus of Valsalva (NSOV)—a structure with complete access to ablate atrial tachycardias. In this issue of Journal of Cardiovascular Electrophysiology (JCE) , Nishimura et al, 1 describe successful ablation of a possible re‐entrant ventricular tachycardia from the NSOV. In addition to the excellent description in their report, cases such as these allow us the opportunity to take a deep dive into the highly nuanced exact regional anatomy of the para‐Hisian area.…”