Trans-subclavian approach for radiofrequency ablation of premature ventricular contractions originating from subtricuspid annulus: a case report
- Teng Li†1, 2,
- Xian-zhang Zhan†1,
- Ping-zhen Yang1,
- Yu-mei Xue1,
- Xian-hong Fang1,
- Hong-tao Liao1 and
- Shu-lin Wu1Email author
© Li et al.; licensee BioMed Central Ltd. 2013
Received: 21 August 2012
Accepted: 30 January 2013
Published: 18 February 2013
Catheter ablation has been established as a curative treatment strategy for ventricular arrhythmias. The standard procedure of most ventricular arrhythmias originating from the right ventricle is performed via the femoral vein. However, a femoral vein access may not achieve a successful ablation in some patients.
We reported a case of a 29-year old patient with symptomatic premature ventricular contractions was referred for catheter ablation. Radiofrequency energy application at the earliest endocardial ventricular activation site via the right femoral vein could not eliminate the premature ventricular contractions. Epicardial mapping could not obtain an earlier ventricular activation when compared to the endocardial mapping, and at the earliest epicardial site could not provide an identical pace mapping. Finally, we redeployed the ablation catheter via the right subclavian vein by a long sheath. During mapping of the subvalvular area of the right ventricle, a site with a good pace mapping and early ventricular activation was found, and premature ventricular contractions were eliminated successfully.
Ventricular arrhythmias originating from the subtricuspid annulus may be successfully abolished via a trans-subclavian approach and a long sheath. Although access via the right subclavian vein for mapping and ablation is an effective alternative, it is not a routine approach.
KeywordsPremature ventricular contractions Tricuspid annulus Radiofrequency catheter ablation
The majority of idiopathic ventricular arrhythmias (VAs), including ventricular tachycardia and premature ventricular contractions (PVCs), have a right ventricular outflow tract or left ventricular outflow tract origin [1–4], but some originate from the aortic sinus cusp , coronary venous system , or mitral annulus . A small number of cases of idiopathic VAs have been reported to originate from the tricuspid annulus . Mapping and catheter ablation of the arrhythmias originating from the tricuspid annulus has been fully understood, and radiofrequency catheter ablation is an effective curative therapy for symptomatic PVCs originating from the vicinity of tricuspid annulus . The standard catheter ablation procedure is performed via the femoral vein. In this case report, a trans-subclavian approach was used for the ablation of PVCs originating from the subtricuspid annulus of the right ventricle.
A 29-year-old man was admitted with frequent premature ventricular contractions. Medical treatment with amiodarone, propafenone and beta-blocker was unsuccessful. He had no other current health problems or history of previous cardiovascular or other major diseases.
The tricuspid annulus has been demonstrated to be one of the major sources of idiopathic VAs originating from the right ventricle . However, to the best of our knowledge, there have been no reports describing frequent PVCs originating from the tricuspid annulus and in which catheter ablation abolished the PVCs via a trans-subclavian approach and a long sheath. For ablation of right-sided cardiac structures, ablation catheters are usually placed through a femoral vein. However, in certain clinical conditions, ablation may be very difficult or even impossible via femoral vein. Efficacy of the superior venous approach in the catheter ablation of atrioventricular reentrant tachycardia and atrial fibrillation had been reported [10, 11]. Delivery of radiofrequency energy in target region resulted in the termination of PVCs via the femoral vein approach, but the PVCs had an immediate reoccurrence. Epicardial origin was suspected, but epicardial mapping could not obtain an earliest activation and pace mapping could not provide an identical match. Finally, we turned to a trans-subclavian approach. Because PVCs could be abolished and reoccurred soon during the first endocardial mapping and ablation, and this may due to an unstable contact of ablation catheter at the subtricuspid annulus via the right femoral vein. Then, the ablation catheter could easily reach the ablation site and have a perfect contact when we used a trans-subclavian approach, and the PVCs could be rapidly and effectively abolished without any reoccurrence via the trans-subclavian approach. Disadvantages of the superior approach such as greater radiation exposure to the ablationist and the challenge of manipulating a catheter and viewing intracardiac electrograms and fluoroscopy images from an unconventional angle have been reported . We introduced a long pre-shaped sheath to avoid these disadvantages and achieved the same efficacy of the femoral vein approach.
The case report presented illustrates a case of access via the right subclavian approach and a long sheath for mapping and ablation of VAs originating from the subtricuspid annulus. Although access via the right subclavian vein for mapping and ablation is not a routine approach, when VAs originating from tricuspid annulus cannot be eliminated by RF application by the routine femoral vein approach, a trans-subclavian approach is an effective alternative, and a long pre-shaped sheath can be applied to avoid the disadvantages of the superior approach.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Premature ventricular contractions
Right ventricular apex.
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