Mapping and ablation on the non-coronary cusp for treating para-Hisian premature atrial contractions and atrial tachycardia

doi:10.3969/j.issn.1004-583X.2025.10.005

Abstract

Abstract:

Objective To evaluate the feasibility, safety, and effectiveness of a noncoronary cusp (NCC) approach to map and ablate premature atrial contractions (PACs) or atrial tachycardia (AT) arising from the para-Hisian region. Methods This retrospective study included 13 consecutive patients treated with radiofrequency ablation under CARTO 3 guidance at Qixingguan District People's Hospital and Guizhou Provincial People 's Hospital between January 2019 and April 2023. Intraoperative electrophysiologic study confirmed that the earliest atrial activation was located at or near the His bundle. Clinical characteristics and procedural data related to NCC mapping and ablation were analyzed. Results Para-Hisian PACs/AT displayed characteristic surface ECG findings. Target sites were within 5 mm of the His bundle. In all 13 patients, NCC mapping identified the earliest local atrial activation preceding the surface P-wave onset by (31.5±15.0) ms. Local electrograms were characterized by a bipolar signal with large A and small V, unipolar QS morphology, and absence of a His bundle potential. Ablation was successful in all cases with no complications observed. Conclusion Para-Hisian PACs/AT present with distinctive ECG features. Guided by these features, three-dimensional electroanatomical mapping with CARTO 3, combined with NCC mapping and ablation, is a safe and effective strategy.

Key words: premature atrial contractions, atrial tachycardia, noncoronary cusp, catheter ablation

CLC Number:

R541.7

Liu Zhenliang, Zhou Yangjie, Wen Wei, Li Wanneng, Xi Binwu, Zhao Xu, Liu Qifang. Mapping and ablation on the non-coronary cusp for treating para-Hisian premature atrial contractions and atrial tachycardia[J]. Clinical Focus, 2025, 40(10): 904-909.

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URL: https://www.lchc.cn/EN/10.3969/j.issn.1004-583X.2025.10.005

https://www.lchc.cn/EN/Y2025/V40/I10/904

Figures/Tables 4

Tab.1 Baseline characteristics

病例	性别	年龄(岁)	心电图诊断	电生理诊断
病例1	男	50	房早	房早
病例2	男	60	房早	房早
病例3	男	51	房早	房早
病例4	男	74	室上性心动过速	房速
病例5	女	53	室上性心动过速	房速
病例6	女	54	室上性心动过速	房速
病例7	女	49	室上性心动过速	房速
病例8	女	67	房速	房速
病例9	男	42	房速	房速
病例10	女	66	房速	房速
病例11	女	45	室上性心动过速	房速
病例12	男	67	房速	房速
病例13	女	37	室上性心动过速	房速

Fig.1 Successful ablation of premature atrial contractions originating near the His bundle region in the NCC a. Preoperative electrocardiogram: P waves are mostly negative/positive biphasic in lead V1 and inferior leads; upright in lead aVR; variable in lead I: low and flat, positive in lead aVL; b. Postoperative electrocardiogram; c. Right atrial mapping, left side is LL (left lateral), right side is LAO (left anterior oblique), yellow points indicate the His bundle, red point shows the earliest activation preceding the surface P wave by 56 ms; d. Fusion image of the aortic sinus and RA:Left side is LL, right side is LAO, yellow points indicate the His bundle, red points indicate the NCC (non-coronary cusp).Note: LL: left lateral

Fig.2 Successful ablation of atrial tachycardias originating near the His bundle region in the NCC a. ECG during atrial tachycardia: P waves appear negative or positive biphasic in lead V1 and inferior leads; upright in lead aVR; negative or positive in lead I, positive in lead aVL; b. ECG after ablation; c. Right atrial (RA) mapping: Left side is RAO (right anterior oblique), right side is LAO (left anterior oblique). Yellow points indicate the His bundle. Mapping near the His bundle septum showed an A wave preceding the surface P wave by 34 ms, but ablation did not terminate the atrial tachycardia; d. Aortic sinus mapping: Left side is RAO, right side is LAO. During atrial tachycardia, mapping showed the earliest local activation at the NCC (non-coronary cusp), preceding the surface P wave by 47 ms, and ablation was successful; e. Fusion image of the RA and aortic sinus: Left side is RAO, right side is LAO. Yellow points indicate the His bundle, red points indicate the earliest activation preceding the surface P wave at the NCC. Note: LCC: Left coronary cusp; RCC: Right coronary cusp; TA: Tricuspid annulus; AO: Aorta

Fig.3 Successful ablation of atrial tachycardias originating near the His bundle region in the NCCA, but ineffective in the right atrium near the His bundle and the left atrium through the interatrial septum a. ECG during arrhythmia: P wave upright in V2-V3, AVL, RP > PR; b. EC after ablation; c. Modeling map of the right atrium: RAO on the left, LAO on the right, yellow is the His bundle, A wave leads the P wave by 51 ms on the interspace surface, ablation ineffective; d. Modeling map of the left atrium: RAO on the left, AP on the; puncture the interatrial septum, local potentials (red) were recorded in the anterior wall of the left atrium in the anterior interspace, which led the P wave by 26 ms, ablation ineffective; e. Modeling map of the aortic sinus: puncture the femoral artery, the aortic sinus was during the arrhythmia, indicating that the local excitation was the earliest to lead the surface P wave by 21 ms, ablation was successful; on the left is RA, on the right is LAO, the yellow dot is the His bundle, the red dot is the earliest to lead the surface P wave by 21Mms, discharge, rial tachycardia terminated; f. Modeling map of the aortic sinus, RA, and LA fusion: RAO on the left, LAO on the, yellow dot is the His bundle, red dot is the earliest to lead the surface P wave in NCC. Note: AP: Anterior-posterior position; RA: Right atrium; LA: Left atrium; AO: aorta

References 18

[1]	Kriatselis C, Roser M, Min T, et al. Ectopic atrial tachycardias with early activation at His site:Radiofrequency ablation through a retro-grade approach[J]. Europace, 2008, 10(6):698-704. doi: 10.1093/europace/eun091.
[2]	Joung B, Lee MH, Kim SS. Successful catheter ablation of atrial tachycardia originating from the non-coronary aortic sinus[J]. Yonsei Med J, 2008, 49(6):1041-1045. doi: 10.3349/ymj.2008.49.6.1041. pmid: 19108031
[3]	Bohora S, Lokhandwala Y, Sternick EB, et al. Reappraisal and new observations on atrial tachycardia ablated from the non-coronary aortic sinus of Valsalva[J]. Europace, 2018, 20(1):124-133. doi: 10.1093/europace/euw324. pmid: 28011797
[4]	王云龙, 任学军, 韩智红, 等. 无冠窦起源房速的电生理特征与射频消融[J]. 临床心电学杂志 2013, 6(22):443-447.doi: 10.1005.0272.06.443.05.
[5]	Chen Y, Xia S, Tao Q, et al. Ablation of atrial tachycardia originating from the noncoronary sinus: Case report and literature review[J]. J Cardiovasc Med (Hagerstown), 2010, 11(5):389-393. doi: 10.2459/JCM.0b013e328332e7cb. pmid: 19809353
[6]	Yamada T, Huizar JF, McElderry HT, et al. Arrial tachycardia originating from the noncoronary aortic cusp and musculature connection with the atria:Relevance for catheter ablation[J]. Heart Rhythm, 2006, 3(12):1494-1496.doi: 10.1016/j.hrthm.2006.08.026.
[7]	Sakai S, Takitsume A, Kawata H. Adenosine-sensitive atrial tachycardia originating from the para-Hisian region with a slow conduction zone in the anteroseptal left atrium[J]. J Cardiol Cases, 2021, 24(2):52-55. doi:10.1016/j.jccase.2020.12.012.
[8]	Ouyang F, Ma J, Ho SY, et al. Focal atrial tachycardia originating from the non-coronary aortic sinus[J]. J Am Coll Cardio, 2006, 1(48), 122-131. doi: 10.1016/j.jacc.2006.02.053.
[9]	蒋周芩, 舒茂琴, 邓盛荣, 等. His束旁起源房性心动过速的电生理特征及射频消融[J]. 中国心脏起搏与电生理杂志, 2020, 3(34), 261-263.doi:10.13333/j.cnki.cjcpe.2020.03.003.
[10]	王云龙, 张俊蒙, 韩智红, 等. 希氏束旁起源房性心动过速心电生理特征及射频消融疗效[J]. 中国循证心血管医学杂志, 2014, 6(6):696-699.doi:CNKI:SUN:PZXX.0.2014-06-013.
[11]	张磊, 贾雄燕, 程媛媛, 等. 射频消融治疗起源于希氏束旁的局灶性房速3例[J]. 心脏杂志, 2018, 30(5):621-622.doi:10.13191/j.chj.2018.0148.
[12]	Lyan E, Toniolo M, Tsyganov A, et al. Comparison of strategies for catheter ablation of focal atrial tachycardia originating near the His bundle region[J]. Heart Rhythm, 2017, 14(7):998-1005. doi: 10.1016/j.hrthm.2017.02.028. Epub 2017 Mar 2. pmid: 28259696
[13]	Beukema RJ, Smit JJ, Adiyaman A, et al. Ablation of focal atrial tachycardia from the non-coronary aortic cusp: Case series and review of the literature[J]. Europace, 2015, 17(6):953-961. doi: 10.1093/europace/euu227. Epub 2014 Sep 18. pmid: 25236180
[14]	余志华, 韩宏伟, 程光辉, 等. 源于His束旁房性心动过速的导管射频消融[J]. 介入放射学杂志, 2015, 24(9):759-762.doi:CNKI:SUN:JRFS.0.2015-09-006.
[15]	Liang M, Wang Z, Liang Y, et al. Different approaches for catheter ablation of Para-Hisian accessory pathways implications for mapping and ablation[J]. Circ Arrhythm Electrophysiol, 2017, 10(6):e004882.doi: 10.1161/CIRCEP.116.004882.
[16]	Zhou YF, Wang Y, Zeng YJ, et al. Electrophysiologic characteristics and radiofrequency ablation of focal atrial tachycardia arising from non-coronary sinuses of Valsalva in the aorta[J]. J Interv Card Electrophysiol, 2010, 28(2):147-151. doi: 10.1007/s10840-010-9481-9.Epub 2010 Apr 16.
[17]	Tada H, Naito S, Miyazaki A, et al. Successful catheter ablation of atrial tachycardia originating near the atrioventricular node from the noncoronary sinus of Valsalva[J]. Pacing Clin Electrophysiol, 2004, 27(10):1440-1443. doi: 10.1111/j.1540-8159.2004.00651.x.
[18]	邓小军, 何运昉, 杨萍, 等. 主动脉无冠窦内导管射频消融治疗希氏束旁起源的房性心动过速临床观察[J]. 中华老年心脑血管病杂志, 2012, 14(2):208.doi:CNKI:SUN:LNXG.0.2012-02-034.