Anatomic approach with bipolar ablation between the left pulmonic cusp and left ventricular outflow tract for left ventricular summit arrhythmias


      Radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) arising from the inaccessible basal region of the left ventricular summit (LVS) is challenging due to proximity to coronary vessels, epicardial fat, and poor radiofrequency (RF) delivery within the distal coronary venous system.


      The purpose of this study was to describe the outcomes of an anatomic approach to inaccessible LVS-VAs using bipolar radiofrequency (Bi-RFCA) delivered from the anatomically adjacent left pulmonic cusp (LPC) to the opposite left ventricular outflow tract (LVOT).


      Patients from 3 centers who had undergone Bi-RFCA for inaccessible LVS-VAs refractory to conventional RFCA using an anatomic approach targeting the adjacent LPC (reversed U approach) with catheter tip pointing inferiorly within the LPC and LVOT were reviewed.


      Seven patients (age 59 ± 12 years; 3 women) underwent Bi-RF from the LPC to the LVOT for LVS-VAs after ≥1 failed conventional RFCA. Bi-RFCA (power 36 ± 7 W; duration 333 ± 107 seconds) resulted in VA suppression in 5 of 7 patients. In 2 cases, Bi-RFCA was successfully performed using dextrose 5% in water. No complications occurred. After mean follow-up of 14 ± 6 months, no recurrent VT was documented in 2 of 2 patients with baseline VT. Mean 84% reduction in premature ventricular contraction (PVC) burden (31% ± 13% vs 4% ± 5% PVCs per day; P = .0027) was documented in the other patients.


      In patients with LVS-VAs arising from the inaccessible region and refractory to conventional RFCA, an anatomic approach using Bi-RFCA from the LPC and opposite LVOT is an effective alternative approach.

      Graphical abstract


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        • Enriquez A.
        • Malavassi F.
        • Saenz L.C.
        • et al.
        How to map and ablate left ventricular summit arrhythmias.
        Heart Rhythm. 2017; 14: 141-148
        • Yamada T.
        • McElderry H.T.
        • Doppalapudi H.
        • et al.
        Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation.
        Circ Arrhythm Electrophysiol. 2010; 3: 616-623
        • Chung F.P.
        • Lin C.Y.
        • Shirai Y.
        • et al.
        Outcomes of catheter ablation of ventricular arrhythmia originating from left ventricular summit: a multicenter study.
        Heart Rhythm. 2020; 17: 1077-1083
        • Zhang J.
        • Tang C.
        • Zhang Y.
        • Su X.
        Pulmonary sinus cusp mapping and ablation: a new concept and approach for idiopathic right ventricular outflow tract arrhythmias.
        Heart Rhythm. 2018; 15: 38-45
        • Futyma P.
        • Kułakowski P.
        Bipolar ablation delivered between the pulmonary and aortic valve cusps.
        Rev Esp Cardiol (Engl Ed). 2019; 72: 1078
        • Barkagan M.
        • Leshem E.
        • Shapira-Daniels A.
        • et al.
        Histopathological characterization of radiofrequency ablation in ventricular scar tissue.
        JACC Clin Electrophysiol. 2019; 5: 920-931
        • Dandamudi S.
        • Kim S.
        • Verma N.
        • Malaisrie C.
        • Tung R.
        • Knight B.
        Left ventricular pseudoaneurysm as a complication of left ventricular summit premature ventricular contraction ablation.
        HeartRhythm Case Rep. 2017; 3: 268-271
        • Watanabe T.
        • Imai Y.
        • Morita E.
        • et al.
        Time course of left ventricular pseudoaneurysm after catheter ablation of LVOT tachycardia.
        JACC Clin Electrophysiol. 2020; 6: 248-249
        • De Maria G.L.
        • Pedersen M.
        • Leo M.
        • Bashir Y.
        • Banning A.P.
        Iatrogenic constrictive remodeling of left main stem after left coronary cusp atrial tachycardia ablation.
        Int J Cardiol. 2015; 184: 507-509
        • Anfinsen O.G.
        • Kongsgaard E.
        • Foerster A.
        • Amlie J.P.
        • Aass H.
        Bipolar radiofrequency catheter ablation creates confluent lesions at larger interelectrode spacing than does unipolar ablation from two electrodes in the porcine heart.
        Eur Heart J. 1998; 19: 1075-1084
        • Nagashima K.
        • Watanabe I.
        • Okumura Y.
        • et al.
        Lesion formation by ventricular septal ablation with irrigated electrodes: comparison of bipolar and sequential unipolar ablation.
        Circ J. 2011; 75: 565-570
        • Nguyen D.T.
        • Tzou W.S.
        • Brunnquell M.
        • et al.
        Clinical and biophysical evaluation of variable bipolar configurations during radiofrequency ablation for treatment of ventricular arrhythmias.
        Heart Rhythm. 2016; 13: 2161-2171
        • Bashir Y.
        • Heald S.C.
        • O’Nunain S.
        • Katritsis D.
        • Camm A.J.
        • Ward D.E.
        Radiofrequency current delivery by way of a bipolar tricuspid annulus-mitral annulus electrode configuration for ablation of posteroseptal accessory pathways.
        J Am Coll Cardiol. 1993; 22: 550-556
        • Teh A.W.
        • Reddy V.Y.
        • Koruth J.S.
        • et al.
        Bipolar radiofrequency catheter ablation for refractory ventricular outflow tract arrhythmias.
        J Cardiovasc Electrophysiol. 2014; 25: 1093-1099
        • Merino J.L.
        • Peinado R.
        • Ramirez L.
        • Echeverria I.
        • Sobrino J.A.
        Ablation of idiopathic ventricular tachycardia by bipolar radiofrequency current application between the left aortic sinus and the left ventricle.
        Europace. 2000; 2: 350-354
        • Koruth J.S.
        • Dukkipati S.
        • Miller M.A.
        • Neuzil P.
        • d’Avila A.
        • Reddy V.Y.
        Bipolar irrigated radiofrequency ablation: a therapeutic option for refractory intramural atrial and ventricular tachycardia circuits.
        Heart Rhythm. 2012; 9: 1932-1941
        • Futyma P.
        • Ciąpała K.
        • Sander J.
        • Głuszczyk R.
        • Futyma M.
        • Kułakowski P.
        Bipolar radiofrequency ablation of ventricular arrhythmias originating in the vicinity of His bundle.
        Circ Arrhythm Electrophysiol. 2020; 13e008165
        • Futyma P.
        • Wysokińska A.
        • Sander J.
        • Futyma M.
        • Kułakowski P.
        Bipolar endo-epicardial radiofrequency ablation of arrhythmia originating from the left ventricular summit.
        Circ J. 2018; 82: 1721-1722
        • Futyma P.
        • Sander J.
        • Ciąpała K.
        • et al.
        Bipolar radiofrequency ablation delivered from coronary veins and adjacent endocardium for treatment of refractory left ventricular summit arrhythmias.
        J Interv Card Electrophysiol. 2020; 58: 307-313
        • Futyma P.
        • Moroka K.
        • Derndorfer M.
        • Kollias G.
        • Martinek M.
        • Pürerfellner H.
        Left pulmonary cusp ablation of refractory ventricular arrhythmia originating from the inaccessible summit.
        Europace. 2019; 21: 1253
        • Nguyen D.T.
        • Tzou W.S.
        • Sandhu A.
        • et al.
        Prospective multicenter experience with cooled radiofrequency ablation using high impedance irrigant to target deep myocardial substrate refractory to standard ablation.
        JACC Clin Electrophysiol. 2018; 4: 1176-1185
        • Futyma P.
        • Ciąpała K.
        • Głuszczyk R.
        • Sander J.
        • Futyma M.
        • Kułakowski P.
        Bipolar ablation of refractory atrial and ventricular arrhythmias: importance of temperature values of intracardiac return electrodes.
        J Cardiovasc Electrophysiol. 2019; 30: 1718-1726
        • Bourier F.
        • Schwarz B.
        • Brkic A.
        • et al.
        EP radiofrequency generators: significant offsets between selected and delivered power?.
        J Cardiovasc Electrophysiol. 2018; 29: 330-334
        • Yue-Chun L.
        • Jia-Feng L.
        • Xue-Qiang G.
        • Peng C.
        Chronic left coronary artery stenosis after radiofrequency ablation of idiopathic premature ventricular contraction originating from left coronary sinus cusp.
        Circ Arrhythm Electrophysiol. 2016; 9e004353
        • Benhayon D.
        • Nof E.
        • Chik W.W.
        • Marchlinski F.
        Catheter ablation in the right ventricular outflow tract associated with occlusion of left anterior descending coronary artery.
        J Cardiovasc Electrophysiol. 2017; 28: 347-350
        • Santangeli P.
        • Marchlinski F.E.
        • Zado E.S.
        • et al.
        Percutaneous epicardial ablation of ventricular arrhythmias arising from the left ventricular summit: outcomes and electrocardiogram correlates of success.
        Circ Arrhythm Electrophysiol. 2015; 8: 337-343
        • Kreidieh B.
        • Rodriguez-Manero M.
        • Schurmann P.
        • Ibarra-Cortez S.H.
        • Dave A.S.
        • Valderrabano M.
        Retrograde coronary venous ethanol infusion for ablation of refractory ventricular tachycardia.
        Circ Arrhythm Electrophysiol. 2016; 9e004352
        • Yang J.
        • Liang J.
        • Shirai Y.
        • et al.
        Outcomes of simultaneous unipolar radiofrequency catheter ablation for intramural septal ventricular tachycardia in nonischemic cardiomyopathy.
        Heart Rhythm. 2019; 16: 863-870
        • Stevenson W.G.
        • Tedrow U.B.
        • Reddy V.
        • et al.
        Infusion needle radiofrequency ablation for treatment of refractory ventricular arrhythmias.
        J Am Coll Cardiol. 2019; 73: 1413-1425
        • Mulpuru S.K.
        • Feld G.K.
        • Madani M.
        • Sawhney N.S.
        A novel, minimally-invasive surgical approach for ablation of ventricular tachycardia originating near the proximal left anterior descending coronary artery.
        Circ Arrhythm Electrophysiol. 2012; 5: e95-e97
        • Neira V.
        • Santangeli P.
        • Futyma P.
        • et al.
        Ablation strategies for intramural ventricular arrhythmias.
        Heart Rhythm. 2020; 17: 1176-1184
        • du Pré B.C.
        • van Driel V.J.
        • van Wessel H.
        • et al.
        Minimal coronary artery damage by myocardial electroporation ablation.
        Europace. 2013; 15: 144-149