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. 2023 Jul;20(7):1018-1025.
doi: 10.1016/j.hrthm.2023.03.1537. Epub 2023 Apr 3.

High-density electroanatomic activation mapping to guide slow pathway modification in patients with persistent left superior vena cava

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High-density electroanatomic activation mapping to guide slow pathway modification in patients with persistent left superior vena cava

Dimitrios Gerontitis et al. Heart Rhythm. 2023 Jul.

Abstract

Background: Slow pathway (SP) mapping and modification can be challenging in patients with persistent left superior vena cava (PLSVC) due to anatomic variance of the Koch triangle (KT) and coronary sinus (CS) dilation. Studies using detailed 3-dimensional (3D) electroanatomic mapping (EAM) to investigate conduction characteristics and guide ablation targets in this condition are lacking.

Objectives: The purpose of this study was to describe a novel technique of SP mapping and ablation in sinus rhythm using 3D EAM in patients with PLSVC after validation in a cohort with normal CS anatomy.

Methods: Seven patients with PLSVC and dual atrioventricular (AV) nodal physiology who underwent SP modification with the use of 3D EAM were included. Twenty-one normal heart patients with AV nodal reentrant tachycardias formed the validation group. High-resolution, ultra-high-density local activation timing mapping of the right atrial septum and proximal CS in sinus rhythm was performed.

Results: SP ablation targets were consistently identified by an area in the right atrial septum with the latest activation time and multicomponent atrial electrogram adjacent to a region with isochronal crowding (deceleration zone). In PLSVC patients, these targets were located at or within 1 cm of the midanterior CS ostium. Ablation in this area led to successful SP modification, reaching standard clinical endpoints with a median of 43 seconds of radiofrequency energy or 14 minutes of cryoablation without complications.

Conclusion: High-resolution activation mapping of the KT in sinus rhythm can facilitate localization and safe SP ablation in patients with PLSVC.

Keywords: Ablation; Atrioventricular nodal reentrant tachycardia; Persistent left superior vena cava; Slow pathway; Three-dimensional electroanatomic mapping.

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