Intracardiac Echocardiography for Subvalvular Ablation of Tricuspid Ring PVCs

Authors: Mária Kohári, MD, PhD; László Sághy, MD, PhD; Róbert Pap, MD, PhD.

Case Synopsis: A 27-year-old female patient with frequent premature ventricular complexes (PVCs) was referred for catheter ablation. The PVC exhibited a left bundle branch block, left axis QRS morphology (Fig. A). During the PVC intracardiac mapping localized the earliest activation at the infero-lateral part of the tricuspid ring. (Fig. B). Only temporary success was achieved by energy delivery at this site. Subsequently, an intracardiac echocardiography (ICE) catheter was introduced for real-time guidance (AcuNav, Biosense Webster) and a steerable sheath (SJM, Agilis sheath) was used, through which the ablation catheter (SmartTouch, SF, Thermocool, Biosense Webster) was looped back under the posterior leaflet of the tricuspid valve (Fig. C and D). At this subvalvular location, radiofrequency ablation resulted in the complete elimination of PVCs. During three years of follow-up, the patient remains free of PVCs.

Discussion: The tricuspid annulus is a common source of idiopathic PVCs originating from the right ventricle. For the elimination of these PVCs, subvalvular placement of the ablation catheter has been described (1.). This case demonstrates the benefit of real-time visualization using ICE during this maneuver.

Reference:

1. Trans-subclavian approach for radiofrequency ablation of premature ventricular contractions originating from subtricuspid annulus: a case report. Teng Li, Xian-zhang Zhan, Ping-zhen Yang et al, BMC Cardiovascular Disorders 2013, 13:7

Figure. A. 12-lead ECG of PVCs. B. Activation map of the right ventricle from RAO view – Pink dots mark the location of ablation. The lower pink sphere marks the successful subvalvular ablation. C. Fluoroscopic image – Position of the ablation catheter in RAO view. D. Intracardiac echocardiography image- It shows the ablation catheter under the tricuspid valve. (ECG= electrocardiogram, PVC= premature ventricular complex, RAO= right anterior oblique, ICE = intracardiac echocardiography, Abl. = ablation catheter)

Video: Intracardiac echocardiography showing the ablation catheter under the posterior leaflet of the tricuspid valve.