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\begin{document}

\title{Successful catheter ablation above aortic sinus cusp approach
eliminating the ventricular arrhythmia arising from the myocardial
crescent beneath the interleaflet triangle : LGE-MRI assessment}



\author[1]{kunihiko kiuchi}%
\author[2]{Yu Izawa}%
\author[2]{Hiroyuki Toh}%
\author[1]{Ken-ichi Hirata}%
\affil[1]{Kobe University Graduate School of Medicine}%
\affil[2]{Kobe University Graduate School of Medicine School of Medicine}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\selectlanguage{english}
\begin{abstract}
A 61-year-old female with 50000 ventricular premature contractions and
reduced left ventricular ejection fraction of 35\% referred to our
center. Although the origin was considered to be originated from the
junction between the left and right coronary cusp, a single
radiofrequency application above the aortic sinus cusp could eliminate
it.%
\end{abstract}%



\sloppy


\textbf{Successful catheter ablation above aortic sinus cusp approach
eliminating the ventricular arrhythmia arising from the myocardial
crescent beneath the interleaflet triangle : LGE-MRI assessment}

Kunihiko Kiuchi, MD, Yu Izawa, MD, Hiroyuki Toh, MD, Ken-ichi Hirata, MD

\emph{Section of Arrhythmia, Division of Cardiovascular Medicine,
Department of Internal Medicine, Kobe University Graduate School of
Medicine}

\emph{7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan}

Key Words: myocardial crescent; interleaflet triangle; ventricular
arrhythmia; radiofrequency catheter ablation;

Conflict of interest

The Section of Arrhythmia is supported by an endowment from Medtronic
JAPAN and Abbott JAPAN. The authors have reported that they have no
relationship relevant to the contents of this paper to disclose.

Funding

None

Short title: Ventricular arrhythmia arising from myocardial crescent

Total word count: 1278

Address: Kunihiko Kiuchi, M.D, (corresponding author)

\emph{Section of Arrhythmia, Division of Cardiovascular Medicine,
Department of Internal Medicine, Kobe University Graduate School of
Medicine}

\emph{7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan}

Fax: (81)-78-382-5859

Telephone: (81)-78-382-5111

E-mail: kunihikokiuchi@yahoo.co.jp

\textbf{Key Clinical Message}

Late gadolinium enhancement magnetic resonance imaging (LGE-MRI) can
visualize the radiofrequency (RF) ablation lesion as well as
pre-existing myocardial fibrosis. The late gadolinium enhancement area
after RF application has a potential accurately to detect the origin of
ventricular arrhythmia.

\textbf{Abstract}

A 61-year-old female with 50000 ventricular premature contractions and
reduced left ventricular ejection fraction of 35\% referred to our
center. Although the origin was considered to be originated from the
junction between the left and right coronary cusp, a single
radiofrequency application above the aortic sinus cusp could eliminate
it.

\textbf{Case history}

A 61-year-old female who slightly felt the dyspnea on effort and was
admitted to our center. 24-hours electrocardiogram (ECG) showed a total
of 50000 ventricular premature contractions (VPC) and the left
ventricular ejection fraction (LVEF) was reduced by 35\%. Although the
origin was likely originated from the junction between the left and
right coronary cusp, catheter manipulation below the cusp was difficult
due to the anatomical reason. Fortunately, a single radiofrequency
application above the right coronary cusp (RCC) near the left coronary
cusp (LCC) -- right coronary cusp (RCC) junction could eliminate the
VPCs. Her symptom disappeared immediately after the procedure, and no
VPC recurred and LVEF was normalized 6 months after the procedure.
LGE-MRI could excellently visualize the RF lesion at the myocardial
crescent beneath the interleaflet triangle.

\textbf{Discussion}

Idiopathic ventricular arrhythmia (VA) from the ostium of the left
ventricle could be eliminated by the radiofrequency (RF) application
within the aortic sinus cusps (ASCs). The VA originating from the
junction between the left and right coronary cusp was rare, however, the
elimination needs to the RF application below the aortic cusps.{[}1{]}
Of interest, this VA had a unique electrocardiographic characteristic of
a qrS pattern in at least one of the leads V1--V3 or abrupt V3
transition (Figure 1A).{[}2, 3{]} The tip of the ablation catheter
should be positioned at this site by deflecting the loop of the ablation
catheter in the left ventricle cavity or on the non-coronary cusp, but
this technique was relatively difficult to stabilize the ablation
catheter due to the limited anatomical space. In the current case,
although electrogram at the ablation catheter was sub-optimal, RF
application at the left coronary cusp (LCC) -- right coronary cusp (RCC)
junction above ACSs could eliminate the VA (Figure 1C). The local
electrogram at the successful ablation site showed a tiny dull
ventricular potential with low R wave amplitude. The distal tip of the
ablation catheter in the fluoroscopy was located behind the coronary
sinus catheter in the right anterior oblique view (Figure 1B, C). These
findings suggest the ablation catheter is more likely to be located
close to the LCC-RCC junction above the ASCs.

To identify radiofrequency lesion extension, high-resolution
late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) was
performed three months after the catheter ablation. The LGE-MRI of ASC
and left ventricle was acquired using a 3D inversion recovery,
respiration navigated, electrocardiogram-gated, T1-FFE sequence in the
transverse plane 15 minutes after the contrast injection, as previously
reported. The typical parameters were as follows: repetition time/echo
time = 4.7 / 1.5 ms, voxel size = 1.43 \selectlanguage{ngerman}× 1.43 × 2.40 mm (reconstructed
to 0.63 × 0.63 × 1.20 mm), flip angle = 15°, SENSE = 1.8, and 80
reference lines. The inversion time (TI) was set at 280 -- 320 ms using
a Look-Locker scan. LGE-MRI could demonstrate that the strong LGE could
be found at the ventricular myocardium beyond the LCC -- RCC junction,
so-called myocardial crescents. However, we have clearly demonstrated
that the LCC -- RCC junction does not involve the myocardial
crescents.{[}4{]} The resign corresponds to the myocardium beneath the
interleaflet triangle, which is located within the left ventricle.
Therefore, it is better reached from the below ASC approach with caution
to the thin interleaflet triangle. In the current case, fortunately, RF
lesion could extent from the myocardial crescent beneath the LCC -- RCC
junction to the myocardium beneath the interleaflet triangle (Figure 2).
In case when the accurate mapping and catheter stability was difficult
beneath the ASCs, careful mapping and RF application at the LCC -- RCC
junction above the ASCs might be acceptable option to eliminate the VA
arising from the myocardium beneath the interleaflet triangle.

\textbf{Acknowledgement}

none

\textbf{Figure Legends}

\textbf{Figure 1}

A: Twelve-lead electrocardiograms during a ventricular arrhythmia and
sinus rhythm. Note that the qrS pattern in V1 and abrupt R-wave
transition in V3. B: Activation map of the ASC (upper panel). Local
electrogram at the successful ablation site (lower panel). The tiny dull
ventricular signal preceded the QRS onset by 28ms. C: A single RF
application could eliminate the VA (upper panel). Ablation catheter
position at the success site in LAO 55 \selectlanguage{english}@ and RAO 30 @ \selectlanguage{english}view (lower
panel).

ABL = ablation catheter, LAO = left anterior oblique, RAO = right
anterior oblique

\textbf{Figure 2}

A: Three-dimensionally reconstructed LGE-MRI of the RV, LV and ASC. The
lower panel shows LV ostium with and without ASC in the cranial view.
The late gadolinium enhancement area (RF lesion) was colored by the
light green. B: RF lesion on the LGE-MRI. The light green arrowhead
indicates the RF lesion at the myocardial crescent just beneath ASC
where the RF lesion likely extent to the myocardial just beneath the
RCC-LCC junction.

ASC = aortic sinus cusp, LAO = left anterior oblique, LCC = left
coronary cusp, NCC = non coronary cusp, RAO = right anterior oblique,
RCC = right coronary cusp

\textbf{Authorship list}

Kunihiko Kiuchi: I mainly described the manuscript.

Yu Izawa: He contributed MRI and 3D visualization.

Hiroyuki Toh: He contributed MRI and 3D visualization.

Koji Fukuzawa: He advised the electrophysiological assessment of VT
ablation.

Mitsuru Takami: He checked the imaging quality in the manuscript.

Ken-ich Hirata: He checked the discussion section in the manuscript.

\textbf{References}

1. Yamada, T., H. T. McElderry, H. Doppalapudi, Y. Murakami, Y. Yoshida,
N. Yoshida, et al. 2008. Idiopathic ventricular arrhythmias originating
from the aortic root prevalence, electrocardiographic and
electrophysiologic characteristics, and results of radiofrequency
catheter ablation. J Am Coll Cardiol. 52:139-147.

2. Yamada, T., N. Yoshida, Y. Murakami, T. Okada, M. Muto, T. Murohara,
et al. 2008. Electrocardiographic characteristics of ventricular
arrhythmias originating from the junction of the left and right coronary
sinuses of Valsalva in the aorta: the activation pattern as a rationale
for the electrocardiographic characteristics. Heart Rhythm. 5:184-192.

3. Liao, H., W. Wei, K. S. Tanager, F. Miele, G. A. Upadhyay, A. D.
Beaser, et al. 2020. Left ventricular summit arrhythmias with an abrupt
V(3) transition: Anatomy of the aortic interleaflet triangle vantage
point. Heart Rhythm.

4. Toh, H., S. Mori, J. T. Tretter, Y. Izawa, S. Shimoyama, M. Suzuki,
et al. 2020. Living Anatomy of the Ventricular Myocardial Crescents
Supporting the Coronary Aortic Sinuses. Semin Thorac Cardiovasc Surg.
32:230-241.\selectlanguage{english}
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