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Direct visualization to facilitate left ventricular summit ablation: Seeing is believing!

  • Francis E. Marchlinski
    Correspondence
    Address reprint requests and correspondence: Dr. Francis E. Marchlinski, University of Pennsylvania Health System, 3400 Spruce St, Founders 9 Pavilion, Philadelphia, PA 19104
    Affiliations
    Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Published:September 21, 2016DOI:https://doi.org/10.1016/j.hrthm.2016.09.017
      The epicardial left ventricular (LV) summit is a common region of origin of idiopathic ventricular arrhythmias and ventricular tachycardia (VT) associated with nonischemic LV cardiomyopathies.
      • Yamada T.
      • McElderry H.T.
      • Doppalapudi H.
      • Okada T.
      • Murakami Y.
      • Yoshida Y.
      • Yoshida N.
      • Inden Y.
      • Murohara T.
      • Plumb V.J.
      • Kay G.N.
      Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation.
      • Hsia H.H.
      • Callans D.J.
      • Marchlinski F.E.
      Characterization of the electrophysiologic substrate in patients with non-ischemic cardiomyopathy and monomorphic ventricular tachycardia.
      Given its proximity to major coronary vessels and anticipated thick layer of epicardial fat, catheter ablation with a percutaneous epicardial approach is challenging.
      • Yamada T.
      • McElderry H.T.
      • Doppalapudi H.
      • Okada T.
      • Murakami Y.
      • Yoshida Y.
      • Yoshida N.
      • Inden Y.
      • Murohara T.
      • Plumb V.J.
      • Kay G.N.
      Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation.
      • Hsia H.H.
      • Callans D.J.
      • Marchlinski F.E.
      Characterization of the electrophysiologic substrate in patients with non-ischemic cardiomyopathy and monomorphic ventricular tachycardia.
      Most VTs successfully ablated via percutaneous epicardial catheter access come from the apical and lateral portions of the summit, where the fat tends to dissipate and recordings directly from the myocardium become possible. These accessible summit VTs typically can be identified by characteristic ECG clues consistent with the described origin but are less common when compared to the summit VTs from the region in closer proximity to the LV base and adjacent to the valvular structures.
      • Santangeli P.
      • Marchlinski F.E.
      • Zado E.S.
      • et al.
      Percutaneous epicardial ablation of ventricular summit: outcomes and ECG predictors of success.
      In this issue of HeartRhythm, Aziz et al
      • Aziz Z.
      • Moss J.
      • Jabbarzadeh M.
      • Hellstrom J.
      • Balkhy H.
      • Tung R.
      Totally endoscopic robotic epicardial ablation of refractory left ventricular summit arrhythmia: first-in-man.
      report on the first-in-man experience of totally endoscopic robotic epicardial ablation of refractory LV summit arrhythmia. The authors are to be commended for their efforts and the clarity of their presentation. The primary issues to consider after reading the report include what alternative strategies are available to achieve equivalent success and which patients can be served by the described new technique.
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      References

        • Yamada T.
        • McElderry H.T.
        • Doppalapudi H.
        • Okada T.
        • Murakami Y.
        • Yoshida Y.
        • Yoshida N.
        • Inden Y.
        • Murohara T.
        • Plumb V.J.
        • Kay G.N.
        Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation.
        Circ Arrhythm Electrophysiol. 2010; 3: 616-623
        • Hsia H.H.
        • Callans D.J.
        • Marchlinski F.E.
        Characterization of the electrophysiologic substrate in patients with non-ischemic cardiomyopathy and monomorphic ventricular tachycardia.
        Circulation. 2003; 108: 704-710
        • Santangeli P.
        • Marchlinski F.E.
        • Zado E.S.
        • et al.
        Percutaneous epicardial ablation of ventricular summit: outcomes and ECG predictors of success.
        Circ Arrhythmia Electropysiol. 2015; 8: 337-343
        • Aziz Z.
        • Moss J.
        • Jabbarzadeh M.
        • Hellstrom J.
        • Balkhy H.
        • Tung R.
        Totally endoscopic robotic epicardial ablation of refractory left ventricular summit arrhythmia: first-in-man.
        Heart Rhythm. 2017; 14: 135-138
        • Baman T.S.
        • Ilg K.J.
        • Gupta S.K.
        • et al.
        Mapping and ablation of epicardial idiopathic ventricular arrhythmias from within the coronary venous system.
        Circ Arrhythm Electrophysiol. 2010; 3: 274-279
        • Mountantonakis S.E.
        • Frankel D.S.
        • Tschabrunn C.M.
        • Hutchinson M.D.
        • Riley M.P.
        • Lin D.
        • Bala R.
        • Garcia F.C.
        • Dixit S.
        • Callans D.J.
        • Zado E.S.
        • Marchlinski F.E.
        Ventricular arrhythmias from the coronary venous system: prevalence, mapping, and ablation.
        Heart Rhythm. 2015; 12: 1145-1153
        • Abularach M.E.J.
        • Campos B.
        • Park K.-M.
        • et al.
        Ablation of ventricular arrhythmias arising near the anterior epicardial veins from the left sinus of Valsalva region: ECG features, anatomic distance and outcome.
        Heart Rhythm. 2012; 9: 865-873
        • Santangeli P.
        • Lin D.
        • Marchlinski F.E.
        Interpretation of complex arrhythmias: a case based approach to catheter ablation of ventricular arrhythmias arising from the left ventricular summit.
        Card Electrophysiol Clin. 2016; 8: 99-107
        • Nagashima K.
        • Choi E.K.
        • Lin K.Y.
        • et al.
        Ventricular arrhythmias near the distal great cardiac vein: challenging arrhythmia for ablation.
        Circ Arrhythm Electrophysiol. 2014; 7: 906-912

      Linked Article

      • Totally endoscopic robotic epicardial ablation of refractory left ventricular summit arrhythmia: First-in-man
        Heart RhythmVol. 14Issue 1
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          The left ventricular (LV) summit presents many of the greatest challenges for catheter ablation of ventricular arrhythmias because of the thickness of the myocardium and complex regional anatomy involving the overlying left atrial appendage, epicardial fat, and the proximal left coronary system. While catheter ablation can be successful in up to 85% of cases of premature ventricular contractions (PVCs),1 the region of the LV summit frequently requires alternative approaches as an adjunct to standard endocardial ablation, including mapping within the coronary venous system, ablation from the left coronary cusp (LCC), and transseptal approach.
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