Fig. 5
PVCs originating from the left ventricular summit were ablated by antegrade transseptal approach. a. PVCs showed the morphology of complete right bundle branch block in precordial leads with precordial transition zone before lead V1, monophasic R in leads II, III, aVF and V3-6, RIII > RII, QS in leads aVL and aVR, QSaVL > QSaVR, rS in lead I. A retrograde transaortic approach was firstly attempted, but failed. The irrigated-tip ablation catheter was then delivered to DCGV via coronary sinus for mapping and ablation. During sinus rhythm, the earliest ventricular activation of PVCs was recorded within DGCV of the left ventricular epicardial summit and preceded QRS wave onset by 32 ms. b. Pacing the site of the earliest ventricular activation within DGCV resulted in a perfect match to spontaneous PVCs in 12 leads. c. The ablation catheter was located in DCGV, and coronary angiography showed that the distance between the tip of ablation catheter and left coronary artery was more than 5 mm. Irrigated RF current was delivered with a target temperature of 43 °C, maximum power output of 25 W, and flow rate of 30 ml/min. After several times of ineffective RFCA in this area, the trans-DGCV approach was abandoned. d. The transseptal approach was finally attempted, by this approach, the activation mapping showed that the earliest ventricular activation recorded in left endocardial summit preceding the QRS onset by 28 ms. e. Pacing the site with the earliest ventricular activation led a poor pace match to spontaneous PVCs,coincidence just in 6 leads of 12 leads. f. Fluoroscopy of the target site by antegrade transseptal approach: The ablation catheter tip was located in the left ventricular endocardial summit, and irrigated RF current was delivered with a target temperature of 43 °C, maximum power output of 35 W, and flow rate of 15 ml/min. The PVCs disappeared after energy delivery for 12.5 s; additional RF current then was applied for another 60s. There was no recurrence during 0.5 years follow-up. Annotation: ABL2 = Ablation catheter in DCGV; ABL1 = Ablation catheter in left ventricular endocardial summit; RFon = RFCA begin