Anatomical vs. electrophysiological approach for ablation of premature ventricular contractions originating from the left ventricular summit (ISESHIMA-SUMMIT Study)
Ryuta Watanabe, Koichi Nagashima, Yasuhiro Shirai, Takayuki Kitai, Takuya Okada, Michifumi Tokuda, Masato Fukunaga, Koumei Onuki, Yosuke Nakatani, Shingo Yoshimura, Seiji Takatsuki, Kenji Hashimoto, Shuhei Yamashita, Masafumi Kato, Fumiya Uchida, Seiji Fukamizu, Rintaro Hojo, Hitoshi Mori, Kazuhisa Matsumoto, Hiroyuki Kato, Kazumasa Suga, Taku Sakurai, Yusuke Sakamoto, Tatsuya Hayashi, Yuji Wakamatsu, Shu Hirata, Moyuru Hirata, Masanaru Sawada, Sayaka Kurokawa, Yasuo Okumura
Abstract
AIMS: Catheter ablation (CA) of idiopathic ventricular arrhythmias (VAs) from the epicardial left ventricular summit is challenging. The endocardial approach targets two sites: the endocardial closest site (ECS) to the epicardial earliest activation site (epi-EAS) and the endocardial earliest activation site (endo-EAS). We aimed to differentiate between cases where CA at the ECS was effective and where CA at the endo-EAS yielded success. METHODS AND RESULTS: Fifty-eight patients (47 men; age 60 ± 13 years) were analysed with VAs in which the EAS was observed in the coronary venous system (CVS). Overall, VAs were successfully eliminated in 42 (72%) patients: 8 in the CVS, 8 where the ECS matched with the endo-EAS, 11 at the ECS, and 15 at the endo-EAS. A successful ECS ablation was associated with a shorter epi-EAS-ECS distance (10.2 ± 4.7 vs. 18.8 ± 5.3 mm; P < 0.001) and shorter epi-EAS-left main coronary trunk (LMT) ostial distance (20.3 ± 7.6 vs. 30.3 ± 8.4 mm; P = 0.005), with optimal cut-off values of ≤12.6 and ≤24.0 mm, respectively. A successful endo-EAS ablation was associated with an earlier electrogram at the endo-EAS [23 (8, 36) vs. 15 (0, 19) ms preceding the QRS; P < 0.001] and shorter epi-EAS-endo-EAS interval [6 (1, 8) vs. 22 (12, 25) ms; P < 0.001], with optimal cut-off values of ≥18 and ≤9 ms, respectively. CONCLUSION: Shorter anatomical distances between the epi-EAS and ECS, and between the epi-EAS and LMT ostium, predict a successful ECS ablation. The prematurity of the endo-EAS electrogram and a shorter interval between the epi-EAS and endo-EAS predicted a successful endo-EAS ablation.