Idiopathic Ventricular Arrhythmias Originating From the Vicinity of the Communicating Vein of Cardiac Venous Systems at the Left Ventricular Summit

Abstract

Background: The communicating vein (CV) between the great cardiac vein and small cardiac venous systems passes between the aortic and pulmonary annulus and is located in close association with the left ventricular summit (summit CV).

Methods and results: Thirty-one patients with idiopathic ventricular arrhythmias (VAs) underwent mapping of the left ventricular summit by using a 2F microcatheter introduced into the summit CV with coronary sinus venographic guidance. Of these, 14 patients were found to have summit-CV VAs. The remaining 17 patients (control group) had VAs originating from the right ventricular outflow tract and the aortic cusps. In patients with summit-CV VAs, the earliest activation during VAs in the summit CV preceded QRS onset by 34.1±5.3 ms. The summit-CV VAs exhibited inferior axis, negative polarity in lead I, deeper QS wave in lead aVL than aVR, and nonspecific bundle branch block morphology with an R/S ratio in lead V₁ of 0.67±0.33, which could be distinguishable from VAs originating from the right ventricular outflow tract and the right coronary cusp. Because of the inaccessibility of the summit CV to ablation catheter, ablation of summit-CV VAs was attempted at adjacent structures where an excellent pacemap was rarely obtained. Overall ablation success was achieved in 10 (71%) patients with summit VAs and 15 (88%) patients in control group (P=0.24).

Conclusions: The myocardium near the summit CV can be the source of idiopathic VAs. Direct monitoring of the summit CV is helpful for identifying the site of origin and provides a landmark of the ablation target, which may facilitate ablation through adjacent structures.

Keywords: catheter ablation; coronary sinus; electrocardiography; electrophysiology; ventricular arrhythmia.