Ventricular Arrhythmias Linked to the Left Ventricular Summit Communicating Veins
A New Mapping Approach for an Old Ablation Problem
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See Article by Komatsu et al
The left ventricular summit (LVS) is the most superior portion of the epicardial LV outflow tract and is a common site of origin of idiopathic ventricular arrhythmias (VAs).1,2 The LVS is anatomically bounded septally by the bifurcation between the left anterior descending and the left circumflex coronary arteries, and transected laterally by the great cardiac vein at the junction with the anterior interventricular vein.3 A proper knowledge of the specific anatomic boundaries within the LVS has substantial clinical relevance with respect to the mapping and ablation approach. The junction between the great cardiac vein and the anterior interventricular vein separates the LVS into an accessible region, lateral to the venous junction and remote from the bifurcation of the left main coronary artery and the epicardial fat around the atrioventricular groove, and an inaccessible region septal to the venous junction and in close proximity to the proximal left coronary arteries and epicardial fat. Although VAs arising from the accessible LVS are rarely problematic and usually can be mapped and ablated from the distal coronary venous system or directly via a percutaneous pericardial approach,2,4 VAs from the inaccessible region represent a major clinical challenge.
Direct epicardial mapping of the inaccessible LVS via a percutaneous epicardial access is limited mainly by the presence of a thick layer of epicardial fat which effectively …