Anatomical Approach from the Coronary Sinus of Valsalva for Para-Hisian Premature Ventricular Contractions: Safety and Outcomes

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Abstract Background While various reports described the characteristics and catheter ablation strategies for para-Hisian premature ventricular contraction (PVC), the patient population were limited in previous literatures and optimal approach remain unknown. This study sought to comprehensively assess the safety and outcomes of catheter ablation for para-Hisian PVC, with a particular focus on the safety and efficacy of ablation from aortic coronary cusps. Methods A total of 122 para-Hisian PVC cases were retrospectively included in this study. The acute and clinical outcomes of ablation, especially the success rate, the rate of conduction system injury, and the ablation site (right side, left side His bundle (HB) region, and aortic coronary cusp), were analyzed. Results Acute procedural success was achieved in 89 patients (73%). However, long-term clinical success (≥80% reduction of PVC burden) was achieved only in 52% of acute-success cases. Cusp ablation was attempted in 35 patients (31%). Cusp ablation was performed significantly more often in clinical-success cases than clinical-failed cases (38% vs.7% P = 0.005), although ablation from multiple locations was still required. In 28 of 35 cases (80%) who underwent cusp ablation, cusp ablation affected PVC by eliminating, transiently suppressing, or changing morphology. Predictors of successful cusp ablation included earlier activation at the cusp and close anatomical proximity to the earliest site at the HB region. Conduction system injury occurred in 31 cases of the entire cohort, mainly during the HB-region ablation, with only one event during cusp ablation. Conclusion In this large cohort of para-Hisian PVC ablation, an anatomical approach from the adjacent coronary cusp ablation can be considered as an effective and safe strategy. Early local activation and a close anatomical proximity between the earliest para-Hisian site and the coronary cusp region are predictors of ablation success with this approach. What is known Catheter ablation of para-Hisian premature ventricular contraction (PVC) is challenging due to the proximity to the His bundle (HB) and/or potentially intramural sources. Catheter mapping and ablation from multiple sites, including aortic coronary cusps, have been reported as potential alternative approaches, however systematic analyses of the ablation outcome and safety for para-Hisian PVC remain scarce. What the study adds Clinical-success rate of radiofrequency (RF) ablation for para-Hisian PVC was still suboptimal (52%). However, the cases undergoing cusp ablation were associated with a better success rate (85%) than those with direct ablation to the HB region alone (42%), indicating this approach may improve the outcome. The anatomical features, including PVC earliest activation site above the HB or within short distance from the coronary cusp, may predict successful PVC elimination from the coronary cusp. Conduction system injury, including minor forms, occurred in approximately 30% cases during the RF ablation near the HB region, while only one AH prolongation observed during cusp ablation, indicating superior safety of cusp ablation.

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