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Background Radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) arising from the inaccessible basal region of the left ventricular summit (LVS) is challenging due to proximity to coronary vessels, epicardial fat, and poor radiofrequency (RF) delivery within the distal coronary venous system. Objective The purpose of this study was to describe the outcomes of an anatomic approach to inaccessible LVS-VAs using bipolar radiofrequency (Bi-RFCA) delivered from the anatomically adjacent left pulmonic cusp (LPC) to the opposite left ventricular outflow tract (LVOT). Methods Patients from 3 centers who had undergone Bi-RFCA for inaccessible LVS-VAs refractory to conventional RFCA using an anatomic approach targeting the adjacent LPC (reversed U approach) with catheter tip pointing inferiorly within the LPC and LVOT were reviewed. Results Seven patients (age 59 ± 12 years; 3 women) underwent Bi-RF from the LPC to the LVOT for LVS-VAs after ≥1 failed conventional RFCA. Bi-RFCA (power 36 ± 7 W; duration 333 ± 107 seconds) resulted in VA suppression in 5 of 7 patients. In 2 cases, Bi-RFCA was successfully performed using dextrose 5% in water. No complications occurred. After mean follow-up of 14 ± 6 months, no recurrent VT was documented in 2 of 2 patients with baseline VT. Mean 84% reduction in premature ventricular contraction (PVC) burden (31% ± 13% vs 4% ± 5% PVCs per day; P = .0027) was documented in the other patients. Conclusion In patients with LVS-VAs arising from the inaccessible region and refractory to conventional RFCA, an anatomic approach using Bi-RFCA from the LPC and opposite LVOT is an effective alternative approach.

Intramural origin of ventricular arrhythmias is one of the reasons for failure of catheter ablation, especially in nonischemic substrates. Conventional unipolar ablation has limited efficacy for the creation of deep transmural lesions in the ventricular myocardium, and alternative ablation strategies have been developed to overcome this problem. These novel approaches include simultaneous unipolar ablation, bipolar ablation, use of low-ionic irrigant solution, needle ablation, and ethanol ablation. This review provides an overview of each one of these techniques, including their main advantages and limitations.

Background Catheter ablation has been considered an effective strategy for the treatment of ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS). However, the inherent complexity of the anatomy of the LVS may result in failed ablation or recurrence of VA. Objective The purpose of this multicenter study was investigate the procedural outcomes of ablation of LVS VA. Methods A total of 238 patients (54.6% men; mean age 53.2 ± 15.0 years) undergoing catheter ablation of LVS VA were included. Baseline characteristics, procedural parameters, and clinical outcomes were analyzed. Results Acute procedural success was achieved in 199 patients (83.6%). Initial epicardial ablation via the coronary venous system (93.8% [91/97]) or percutaneous transpericardial approach (6.2% [6/97]) achieved successful ablation in 40 of 97 patients (41.2%), and VA was eliminated by initial approaches from the aortic sinus of Valsalva or subvalvular endocardium in 68 of 139 patients (48.9%; P = .29). Multisite ablations were performed in the process of acute VA elimination in 105 patients (51.8%), and 7 complications occurred. During median follow-up of 26 (1–87) months, 82.2% of patients with acute success were free from VA recurrences, and the overall long-term success rate was 68.1%. Multisite ablation was the only independent predictor of VA recurrences. Conclusion Acute elimination of VA originating from the LVS could be achieved in 83.6% of patients, with 82.2% having no VA recurrences. Despite acute elimination of VA with multisite ablation, the incidence of VA recurrence still was high.