An Alternative Way to Reach the Ventricular Surface of the
Sinuses of Valsalva: Antegrade Transseptal Approach
Serkan Cay, MD; Ozcan Ozeke, MD; Firat Ozcan, MD; Serkan Topaloglu, MD;
Dursun Aras, MD
Department of Cardiology, Division of Arrhythmia and Electrophysiology,
University of Health
Sciences, Ankara City Hospital, Ankara, Turkey
Correspondence
Serkan Cay, MD
Department of Cardiology,
Division of Arrhythmia and Electrophysiology,
University of Health Sciences, Ankara City Hospital,
Bilkent, 06800 Cankaya, Ankara, Turkey
E-mail:
cayserkan@yahoo.com
To the Editor,
We have read with great interest the article entitled ‘Left Sinus of
Valsalva – Electroanatomic Basis and Outcomes with Ablation for Outflow
Tract Arrhythmias’ by Kapa et al1 in the latest issue
of the journal. We would like to thank the authors for conceptualizing
an idea about the common ablation point for outflow tract ventricular
arrhythmias with different ECG characteristics, suggesting different
origins. In the current study, operators reached the area below the left
sinus of Valsalva using the catheter inversion technique via the
retrograde transaortic route. In some cases, ablation attempts cannot be
successful with this approach and even with the use of a long sheath
although effective in most patients. In addition, the operator cannot
reach the aortic route because of anatomic obstacles in the arterial
system occasionally. Catheter manipulation, contact and the stability
might be challenging using the catheter inversion technique due to
various anatomical reasons including highly mobile aortic valve leaflets
and increased dimensions of the aortic root and the left ventricle in
some cases.
The antegrade transseptal approach is routinely used to reach the
infravalvular region in some centers. There are some fine details with
the antegrade transseptal approach using a ‘reverse S’ shape of the
mapping catheter. To reach the ventricular surface of anteriorly and
superiorly located aortic cusps more comfortably, one should be
performed the transseptal puncture from the anterior and inferior region
of the interatrial septum, posterior to the non-coronary cusp using
either a fluoroscopic marker (angiography or mapping catheter) or
imaging tool (intracardiac or transesophageal echo). With the help of
the long sheath (SL1™, Abbott or Preface®, Biosense Webster), the
mapping catheter can form a ‘reverse S’ curve and clockwise and
counter-clockwise movements rotate the catheter toward the left and
right cusps, respectively,
The figure demonstrates a case with premature ventricular complexes
originating from below the right coronary cusp and mapping and ablation
using the antegrade transseptal approach (Supplementary Videos).
Keywords: cusp; reverse S; transaortic; transseptal