Radiofrequency catheter ablation of premature ventricular contractions from the mitral annulus in patients without structural heart disease

Abstract

Introduction: We previously reported the clinical benefits of radiofrequency catheter ablation (RFCA) of premature ventricular contractions (PVCs) from the right ventricular outflow tract or near the His-bundle, which can often deteriorate the clinical status. PVCs from the mitral valve (MA-PVCs) also often deteriorate the patients' clinical status. This study aimed to evaluate the effect of ablating MA-PVCs with RFCA from a trans-interatrial septal approach on the clinical status in symptomatic patients with frequent MA-PVCs without structural heart disease.

Methods: The frequency of PVCs per the total heart beats by 24-hours Holter monitoring and New York Heart Association (NYHA) functional class in 22 patients with MA-PVCs were evaluated before and 6 months after RFCA.

Results: Procedural success was achieved in 20 (91%) of 22 patients. Of the 22 patients, in 15 (68%) and 1 (5%) patient, a successful RFCA on the left ventricular side of the MA using the trans-interatrial septal approach and trans-coronary sinus approach was achieved. Interestingly, in four (18%) patients, a successful RFCA on the left atrial (LA) side of the MA using a trans-interatrial septal approach was achieved. Ablating MA-PVCs readily improved the NYHA functional class compared to that before. A ≥0.62 peak deflection index and ≤30 years old may be one of the important predictors of successfully ablated MA-PVCs from the LA side of the MA.

Conclusions: RFCA produces clinical benefits in patients with MA-PVCs. Further, it may be necessary to initially consider a trans-interatrial septal approach to ablate these PVCs.

Keywords: catheter ablation; clinical characteristics; clinical status; mitral annulus; premature ventricular contraction; trans-interatrial septal approach.

FIGURE 1

The 12‐lead electrocardiograms in the patients with premature ventricular contractions from the mitral annulus (MA) (A). The EnSite™ 3D‐mapping images of the earliest activation sites during the culprit PVCs (BE), intracardiac electrocardiograms (CF), and 12 ECGs during the pace map (DG) at the successful ablation sites on the ventricular side of the MA (BCD) or left atrium side of the MA (EFG) with the trans‐interatrial septal approach

FIGURE 1

The 12‐lead electrocardiograms in the patients with premature ventricular contractions from the mitral annulus (MA) (A). The EnSite™ 3D‐mapping images of the earliest activation sites during the culprit PVCs (BE), intracardiac electrocardiograms (CF), and 12 ECGs during the pace map (DG) at the successful ablation sites on the ventricular side of the MA (BCD) or left atrium side of the MA (EFG) with the trans‐interatrial septal approach

FIGURE 2

The left atrio‐ and ventriculography (A) and the approach sites of the radiofrequency catheter ablation on the ventricular side of the mitral annulus (MA) from the supramitral valve (B), inframitral valve (C), and left atrial side of the MA (D) from the trans‐interatrial septal approach, from the trans‐coronary sinus approach (E), and from the trans‐aortic approach (F). The LA, LV, MV, ABL, CS, and His‐RV indicate the left atrium, left ventricle, mitral valve, ablation catheter, coronary sinus, and His‐bundle and right ventricle, respectively. The upper and middle and lower panels were the right (RAO) and left anterior oblique (LAO) view of the LA and LV, respectively. The red, blue, and water blue bar indicate the ablation catheter and the electrodes placed on the CS and His‐RV, respectively

FIGURE 3

The earliest activation sites of the premature ventricular contractions from the MA with a successful (red, blue, green, and purple circles; n = 20) or unsuccessful (black circle; n = 2) radiofrequency catheter ablation in the LAO view of the MA. The red, blue, green, and purple circles indicate successful ablation sites on the ventricular side of the MA from the supramitral valve (Figure 2B), inframitral valve (Figure 2C), and LA side of the MA (Figure 2D) from the trans‐interatrial septal approach and trans‐coronary sinus approach (Figure 2E), respectively

FIGURE 4

The ROC curve analysis of the peak deflection index (PDI) (A) and age (B) at the time the successful ablation was performed at a site on the left atrial (LA) side of the mitral annulus (MA) in patients with premature ventricular contractions from the MA. Their specificity and sensitivity were 0.800 and 1.000 at a PDI of 0.62 and 1.000 and 0.750 for 30 years old, respectively. The area under the curve (AUC) was 0.908 and 0.925, respectively