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A novel approach to mapping and ablation of septal outflow tract ventricular arrhythmias: Insights from multipolar intraseptal recordings

      Catheter ablation is the preferred treatment option for idiopathic ventricular arrhythmias (VAs).
      • Sapp J.L.
      • Wells G.A.
      • Parkash R.
      • et al.
      Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs.
      Refinements in mapping and ablation technologies have led to a marked improvement in success rates of catheter ablation. Despite these improvements, VAs arising from specific anatomical locations such as the left ventricular summit (LVS) and the interventricular septum pose specific challenges to mapping and delivery of radiofrequency (RF) energy. A major obstacle in treating VAs from these sites is the inaccessibility of mapping from the endocardium or epicardium or the presence of intramural substrate that is challenging to record and target efficiently with standard techniques. Improved ablation delivery systems such as using half normal saline, bipolar ablation, and needle tip ablation have been proposed as alternative ablation strategies to target these difficult areas.
      • 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.
      • 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.
      • Sapp J.L.
      • Beeckler C.
      • Pike R.
      • et al.
      Initial human feasibility of infusion needle catheter ablation for refractory ventricular tachycardia.
      However, the results have not been consistently successful and perhaps the inability to record and understand the precise focal origin or arrhythmic circuits has limited our success with ablation. With increased understanding of cardiac anatomy and relevant neighboring structures of the LVS, delivery of RF energy from close vantage points is commonly practiced with variable success rates. However, a systematic approach of choosing the site of ablation on the basis of the results of detailed mapping is unclear. The coronary venous system provides an additional dimension of mapping VAs arising from the LVS and basal interventricular septal regions. Specifically, the septal perforating veins draining into the anterior interventricular vein (AIV) course parallel to the septal perforating branches of the left anterior descending artery and can be used for mapping these intramural foci in the septum. We previously reported our experience with intramural mapping of LVS arrhythmias using intramural coronary venous unipolar wire mapping.
      • Briceño D.F.
      • Enriquez A.
      • Liang J.J.
      • et al.
      Septal coronary venous mapping to guide substrate characterization and ablation of intramural septal ventricular arrhythmia.
      In this report, we describe a novel technique of mapping intramurally with multiple bipolar recordings to understand the activation patterns of VAs in 3-dimensional space and design the optimal ablation strategy.

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