Zero-Fluoroscopy Ablation of Coronary Cusp Ventricular Arrhythmias by the Below-Valve Approach

ZF in CC VAs using below-valve approach

Abstract

Background: Catheter ablation (CA) of ventricular arrhythmias (VAs) arising from the aortic coronary cusps (CC) is highly effective but requires high-dose fluoroscopy to limit vascular damage of the coronary arteries. Intracardiac echocardiography (ICE) permits near-zero (NZ) or zero fluoroscopy (ZF) through examination of coronary ostia. The below-valve approach (BVA) without ICE guidance might be safe for ZF ablation of CC VAs.
Objective: The aim of the current study was to assess the feasibility of ZF CA of CC VAs by BVA using three-dimensional electroanatomic mapping (3D-EAM) systems.
Methods: This was a single-center study where ablation procedures were attempted with the ZF or NZ approach in 57 consecutive patients with CC VAs under the support of the 3D-EAM system. All cases where ablation was on a defined region specifically inferior to the aortic sinus of valsalva have been included in the BVA group, whereas the patients who need fluoroscopy at any level during the procedure and/or all supravalvular CC ablations [also called as the above-valve approach (AVA)] were evaluated under the NZ group as a control group.
Results: A total of 21 consecutive cases of ZF for CC CA were included in the primary analysis (mean age, 49 ± 14 years old; 62% male; mean ejection fraction, 58 ± 9%). After 1 month, the success was noted in 19 of 21 (90%) cases. The use of ZF was achieved in 37% of all CC VAs, but 91% of all BVA group, particularly in the LCC-RCC commissure region (88%). Two (6%) patients required limited fluoroscopy due to the inability to advance the catheter from descending aorta to ascending aorta despite long sheath use.
Conclusion: ZF CA of CC VAs by BVA using 3D-EAM is feasible and effective, particularly in LCC-RCC commissure VAs in the absence of ICE guidance.