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Comparative Study
. 2024 Nov 1;26(11):euae278.
doi: 10.1093/europace/euae278.

Anatomical vs. electrophysiological approach for ablation of premature ventricular contractions originating from the left ventricular summit (ISESHIMA-SUMMIT Study)

Ryuta Watanabe  1 , Koichi Nagashima  1 , Yasuhiro Shirai  2 , Takayuki Kitai  3 , Takuya Okada  4 , Michifumi Tokuda  5 , Masato Fukunaga  6 , Koumei Onuki  6 , Yosuke Nakatani  7 , Shingo Yoshimura  7 , Seiji Takatsuki  8 , Kenji Hashimoto  8 , Shuhei Yamashita  8 , Masafumi Kato  9 , Fumiya Uchida  9 , Seiji Fukamizu  10 , Rintaro Hojo  10 , Hitoshi Mori  11 , Kazuhisa Matsumoto  11 , Hiroyuki Kato  12 , Kazumasa Suga  12 , Taku Sakurai  12 , Yusuke Sakamoto  13 , Tatsuya Hayashi  14 , Yuji Wakamatsu  1 , Shu Hirata  1 , Moyuru Hirata  1 , Masanaru Sawada  1 , Sayaka Kurokawa  1 , Yasuo Okumura  1
Affiliations
Comparative Study

Anatomical vs. electrophysiological approach for ablation of premature ventricular contractions originating from the left ventricular summit (ISESHIMA-SUMMIT Study)

Ryuta Watanabe et al. Europace. .

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.

Keywords: Anatomical approach; Electrophysiological approach; Idiopathic ventricular arrhythmias; Left ventricular summit.

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Conflict of interest statement

Conflict of interest: K.N. received speaker honoraria from Johnson & Johnson, Medtronic Japan, Boston Scientific Japan, Abbott Japan, and Daiichi-Sankyo. S.T. received honoraria from Medtronic Japan, Daiichi-Sankyo, Johnson & Johnson, Boston Scientific Japan, Abbott Japan, Bayer Yakuhin, and Japan Lifeline and is affiliated with the endowed research courses supported by Medtronic Japan, Japan Lifeline, Boston Scientific Japan, Abbott Japan, and Biotronik Japan. Y.O. received research grants unrelated to this study from Johnson & Johnson KK and Biosense Webster, Inc., scholarship funds from Nippon Boehringer Ingelheim, and remuneration from Daiichi-Sankyo, AstraZeneca, Bayer Healthcare, Bristol-Myers Squibb, and Johnson & Johnson KK and additionally belongs to the endowed departments of Boston Scientific Japan, Biotronik Japan, Abbott Medical Japan, Japan Lifeline, and Medtronic Japan. All remaining authors have declared no conflicts of interest.

Figures

Graphical Abstract
Graphical Abstract
The estimated mechanisms underlying the successful ablation of (A) the ECS and (B) endo-EAS. The anatomical distances between the epi-EAS and ECS of ≤12.6 mm and between the epi-EAS and LMT ostium of ≤24.0 mm are the determinants of a successful ablation at the ECS. The electrogram at the endo-EAS preceding the QRS by ≥18 ms and the interval of the electrograms between the epi-EAS and endo-EAS of ≤9 ms are the determinants for a successful ablation at the endo-EAS. The details are described in the Discussion. The abbreviations are as shown in Figure 3.
Figure 1
Figure 1
The tagging method of the EAS in the epicardium and LMT using the CARTO system. (A) Local electrograms recorded at the epi-EAS, endo-EAS, and ECS. The solid line represents the activation of the local electrogram, and the dotted line indicates the onset of the surface QRS. (B) After completing the endocardial activation mapping, the position of the multielectrode wire catheter can be displayed on the CARTO 3 system. A pink tag is also placed on the ostium of the LMT. The white arrow indicates the epi-EAS location seen in AIV5-6. (C) The green tag indicates the epi-EAS placed on the CARTO system, utilizing a sound-based geometry, where the fan of the CARTOSOUND is used to traverse the long axis of the wire catheter. (D) The orange tag is the ECS of the endocardial site closest to the tagged epi-EAS. The blue tag is the endo-EAS. Abbreviations: ABL, ablation catheter; AIV, anterior interventricular vein; aVF, augmented vector foot; aVL, augmented vector left; aVR, augmented vector rihgt; ECS, endocardial closest site; endo-EAS, endocardial earliest activation site; epi-EAS, epicardial earliest activation site; LCC, left coronary cusp; LMT, left main coronary trunk; LV, left ventricle; NCC, non-coronary cusp; RCC, right coronary cusp.
Figure 2
Figure 2
The flow chart of the mapping and ablation procedure. The ablation sites are depicted with consistent colour coding for each tag as used in Figure 1. Abbreviations: ECS, endocardial closest site; endo-EAS, endocardial earliest activation site; epi-EAS, epicardial earliest activation site; LV, left ventricle; RF, radiofrequency; VAs, ventricular arrhythmias.
Figure 3
Figure 3
Receiver operating characteristic curves predicting (A) successful ablation in the ECS and (B) successful ablation in the endo-EAS. Abbreviations: AUC, area under the curve; LMT, left main coronary trunk; the others are as shown in Figure 2.
Figure 4
Figure 4
The flow chart of the recommended endocardial ablation strategies for VAs originating from the LVS. Abbreviations: CVS, coronary venous system; the others are as shown in Figure 3.
See this image and copyright information in PMC

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