Anatomical approach to suppression of para-Hisian ventricular arrhythmias with changes in QRS morphology after ablation at the earliest activation site

Yuichiro Sagawa; Tetsuya Asakawa; Takatoshi Shigeta; Kazuya Murata; Hirofumi Arai; Atsuhito Oda; Manabu Kurabayashi; Koji Miyamoto; Akihiro Takitsume; Masahiro Yoshinaga; Kazuya Nakagawa; Shozo Ishihara; Kaoru Okishige; Tetsuo Sasano; Yasuteru Yamauchi

doi:10.1016/j.hrthm.2024.05.036

Anatomical approach to suppression of para-Hisian ventricular arrhythmias with changes in QRS morphology after ablation at the earliest activation site

Heart Rhythm. 2024 May 24:S1547-5271(24)02630-4. doi: 10.1016/j.hrthm.2024.05.036. Online ahead of print.

Authors

Affiliations

¹ Department of Cardiology, Japan Red Cross Yokohama City Bay Hospital, Kanagawa, Japan. Electronic address: yuichiro.sagawa1111@gmail.com.
² Cardiology Division, Yamanashi Kosei Hospital, Yamanashi, Japan.
³ Department of Cardiology, Japan Red Cross Yokohama City Bay Hospital, Kanagawa, Japan.
⁴ Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.
⁵ Department of Cardiology, Nara Prefecture General Medical Center, Nara, Japan.
⁶ Department of Cardiology, Saiseikai Izuo Hospital, Osaka, Japan.
⁷ Department of Cardiology, Mimihara General Hospital, Osaka, Japan.
⁸ Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan.

PMID: 38797309
DOI: 10.1016/j.hrthm.2024.05.036

Abstract

Background: The anatomical approach for the management of para-Hisian ventricular arrhythmias (VAs) with QRS morphological changes after catheter ablation (CA) has not been well investigated.

Objective: We aimed to evaluate the electrocardiographic and electrophysiological findings and ablation outcomes of para-Hisian VAs with QRS morphological changes after CA.

Methods: Of the 30 patients who underwent CA for para-Hisian VAs at 4 institutions, 10 (33%) had QRS morphological changes after ablation. All 10 patients underwent an anatomical approach, targeting the site anatomically opposite to the site where the QRS morphology had been changed by ablation. We investigated the safety and efficacy of the anatomical approach.

Results: Of the 10 patients evaluated, the approach was switched from the right ventricular septum to the left ventricular septum/aortic root in 7 (70%) (RL group) whereas 3 (30%) underwent left-to-right switches (LR group). After CA, the precordial transition zone tended to be earlier in the RL group and later in the LR group. In the RL group, successful VA suppression was achieved, despite suboptimal pace map concordance from the left side or a relatively delayed earliest activation time. Of the 10 patients who underwent an anatomical approach, 8 (80%) had procedural success, and ablation was discontinued in 1 (10%) because of the risk of atrioventricular block.

Conclusion: The anatomical approach showed promising results regarding safety and efficacy. Therefore, it should be considered when QRS morphological changes are observed during or after CA of para-Hisian VAs.

Keywords: Anatomical approach; Catheter ablation; Para-Hisian region; QRS morphological change; Ventricular arrhythmias.