Search

Objectives This study investigates the effect of stellate ganglion (SG) phototherapy in healthy participants and assesses its efficacy in suppressing electrical storm (ES) refractory to an...

The therapeutic strategy for sustained ventricular tachycardia (VT) during left ventricular assist device usage remains unclear. We encountered a patient with durable left ventricular assist device who presented sustained VT. Electrophysiological mapping was able to be established appropriately owing to the robust mechanical hemodynamics support despite inter-device interference. The three-dimensional activation map of clinically documented VT demonstrated that the propagation exited from the right ventricular apex through the critical isthmus located at the epicardium or interventricular septum, which was successfully treated by catheter ablation at the exit site. Further experiences like ours should be accumulated to establish a therapeutic strategy.

Objectives This study sought to demonstrate a new type of verapamil-sensitive fascicular ventricular tachycardia (VT) with a reverse circuit. Background Left posterior fascicular ventricular tachycardia (LPFVT) is the most common form of verapamil-sensitive fascicular VT. Reverse-type LPFVT has not been reported. Methods We searched for a reverse-type LPFVT among 242 patients with verapamil-sensitive VT from February 2006 to September 2019. Results Three patients had a reverse-type LPFVT (cycle lengths: 340, 360, and 340 ms). QRS configuration during VT was narrow (140, 150, and 140 ms) and exhibited rSr’ morphology in V1 with an early precordial transition and inferior axis. Two of 3 patients had common-type LPFVT. During reverse-type LPFVT, the earliest ventricular activation was the left superior middle septum. Fragmented Purkinje potentials (P1) buried within the local ventricular electrogram were recorded with an activation sequence from the apex to the base and were linked to the subsequent left ventricular septal activation. After radiofrequency catheter ablation at P1 during LPFVT, the reverse-type LPFVT also became noninducible. In 1 patient with only the reverse-type LPFVT, radiofrequency catheter ablation at the earliest LV activation site suppressed VT. These findings suggest that this new type of verapamil-sensitive fascicular VT shares a re-entrant circuit with a reverse direction of common LPFVT with an intramural exit site at the superior middle septum. Conclusions Reverse-type LPFVT can occur. If common LPFVT exists, diastolic P1 during LPFVT can be a common target of ablation. If only reverse-LPFVT is inducible, the earliest ventricular activation site can be a target.

Background: Catheter ablation as first-line therapy for ventricular tachycardia (VT) at the time of implantable cardioverter defibrillator (ICD) implantation has not been adopted into clinical guidelines. Also, there is an unmet clinical need to prospectively examine the role of VT ablation in patients with nonischemic cardiomyopathy, an increasingly prevalent population that is referred for advanced therapies globally. Methods: We conducted an international, multicenter, randomized controlled trial enrolling 180 patients with cardiomyopathy and monomorphic VT with an indication for ICD implantation to assess the role of early, first-line ablation therapy. A total of 121 patients were randomly assigned (1:1) to ablation plus an ICD versus conventional medical therapy plus an ICD. Patients who refused ICD (n=47) were followed in a prospective registry after stand-alone ablation treatment. The primary outcome was a composite end point of VT recurrence, cardiovascular hospitalization, or death. Results: Randomly assigned patients had a mean age of 55 years (interquartile range, 46–64) and left ventricular ejection fraction of 40% (interquartile range, 30%–49%); 81% were male. The underlying heart disease was ischemic cardiomyopathy in 35%, nonischemic cardiomyopathy in 30%, and arrhythmogenic cardiomyopathy in 35%. Ablation was performed a median of 2 days before ICD implantation (interquartile range, 5 days before to 14 days after). At 31 months, the primary outcome occurred in 49.3% of the ablation group and 65.5% in the control group (hazard ratio, 0.58 [95% CI, 0.35–0.96]; P =0.04). The observed difference was driven by a reduction in VT recurrence in the ablation arm (hazard ratio, 0.51 [95%CI, 0.29–0.90]; P =0.02). A statistically significant reduction in both ICD shocks (10.0% versus 24.6%; P =0.03) and antitachycardia pacing (16.2% versus 32.8%; P =0.04) was observed in patients who underwent ablation compared with control. No differences in cardiovascular hospitalization (32.0% versus. 33.7%; hazard ratio, 0.82 [95% CI, 0.43–1.56]; P =0.55) or mortality (8.9% versus 8.8%; hazard ratio, 1.40 [95% CI, 0.38–5.22]; P =0.62]) were observed. Ablation-related complications occurred in 8.3% of patients. Conclusions: Among patients with cardiomyopathy of varied causes, early catheter ablation performed at the time of ICD implantation significantly reduced the composite primary outcome of VT recurrence, cardiovascular hospitalization, or death. These findings were driven by a reduction in ICD therapies. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02848781.

Prebiotics ameliorate dysbiosis and influence metabolism and the immune system, but their effects on cardiovascular complications in metabolic disorders remain largely unknown. We here investigated the effects of the soluble fiber inulin on cardiac, adipose tissue, and hepatic pathology as well as on metabolic disorders in DahlS.Z-Lepr^fa/Lepr^fa (DS/obese) rats, an animal model of metabolic syndrome (MetS). DS/obese rats and their homozygous lean (DahlS.Z-Lepr^+/Lepr^+, or DS/lean) littermate controls were fed a purified diet containing 5% or 20% inulin from 9 to 13 wk of age. The high-fiber diet ameliorated hypertension, left ventricular inflammation, fibrosis and diastolic dysfunction; attenuated adipose tissue inflammation and fibrosis; and alleviated the elevation of interleukin-6 levels, without affecting insulin resistance, in DS/obese rats. In addition, high fiber intake ameliorated lipid accumulation, inflammation, and fibrosis; attenuated the reduction in AMPK activity; upregulated sterol regulatory element-binding protein-1c gene expression; and increased the expression of microsomal triglyceride transfer protein gene in the liver of DS/obese rats. It also mitigated increases in total and non-high-density lipoprotein cholesterol levels but increased the triglyceride concentration in serum in these rats. None of these parameters were affected by high dietary fiber in DS/lean rats. The proportion of regulatory T cells in adipose tissue was influenced by dietary fiber but not by genotype. Our results indicate that inulin exacerbates hypertriglyceridemia but alleviates hypertension and cardiac injury as well as adipose tissue and hepatic pathology in MetS rats.

Catheter ablation is a therapeutic option to suppress ventricular tachycardia (VT) in the setting of dilated-phase hypertrophic cardiomyopathy (DHCM). However, the characteristics of the arrhythmogenic substrate and the ablation outcome are not fully illustrated.A total of 23 ablation procedures for drug-refractory sustained monomorphic VTs in 13 DHCM patients (60 ± 11 years, one female, the left ventricular [LV] ejection fraction 39% ± 9%, the LV mass index 156 ± 39 g/mTwo patients underwent ablation of sustained monomorphic VT that was not scar-mediated tachycardia. Of the remaining 11 patients, eight (73%) patients had VT substrate in the basal regions, most frequently at the epicardial and/or intramural basal antero-septum. None of the patients had VT substrate located at the LV inferolateral region. Ablation at the right ventricular septum and the aortic cusps was done in four and five patients, respectively. Other approaches including bipolar and chemical ablations, were done in three and two patients, respectively. Six (55%) out of 11 patients (two patients lost follow-up) had VT recurrence. All the six patients had basal substrate. However, anti-tachycardia pacing was sufficient for VT termination except in one patient.Catheter ablation of VT in patients with DHCM is challenging because of the predominant basal anteroseptal epicardial/intramural location of arrhythmogenic substrate. An ablation approach from multiple sites and/or adjunctive interventional techniques are often required.

Supplemental Digital Content is available in the text., Background: Recent advancements in a 3-dimensional mapping system allow for the assessment of detailed conduction properties during sinus rhythm and thus the establishment of a strategy targeting functionally abnormal regions in scar-related ventricular tachycardia (VT). We hypothesized that a rotational activation pattern (RAP) observed in maps during baseline rhythm was associated with the critical location of VT. Methods: We retrospectively examined the pattern of wavefront propagation during sinus rhythm in patients with scar-related VT. The prevalence and features of the RAP on critical VT circuits were analyzed. RAP was defined as >90° of inward curvature directly above or at the edge of the slow conductive areas. Results: Forty-five VTs in 37 patients (66±15 years old, 89% male, 27% ischemic heart disease) were evaluated. High-density substrate mapping during sinus rhythm (median, 2524 points) was performed using the CARTO3 system before VT induction. Critical sites for reentry were identified by direct termination by radiofrequency catheter ablation in 21 VTs or by pace mapping in 12 VTs. Among them, RAP was present in 70% of the 33 VTs. Four VTs had no RAP at the critical sites during sinus rhythm, but it became visible in the mappings with different wavefront directions. Six VTs, in which intramural or epicardial isthmus was suspected, were rendered noninducible by radiofrequency catheter ablation to the endocardial surface without RAP. RAP had a sensitivity and specificity of 70% and 89%, respectively, for predicting the elements in the critical zone for VT. Conclusions: The critical zone of VT appears to correspond to an area characterized by the RAP with slow conduction during sinus rhythm, which facilitates targeting areas specific for reentry. However, this may not be applicable to intramural VT substrates and might be affected by the direction of wavefront propagation to the scar during mapping. Graphic Abstract: A graphic abstract is available for this article.

Aims The precise localization of manifest posteroseptal accessory pathways (APs) often poses diagnostic challenges considering that a small area may encompass AP that may be ablated from the right or left endocardium, or epicardially within the coronary sinus (CS). We sought to explore whether the QRS transition pattern in the precordial lead may help to discriminate the necessary ablation approach. Methods and results Consecutive patients who underwent a successful ablation of a single manifest AP over a 5-year period were included. Standard 12-lead electrocardiograms were reviewed. A total of 273 patients were identified. Mean age was 31 ± 15 years and 62% were male. Of the 110 identified posteroseptal AP, 64 were ablated from the right endocardium, 33 from the left endocardium, and 13 inside the CS. While a normal precordial QRS transition was most often observed, a subset of 33 patients presented an atypical ‘double transition’ pattern which specifically identified right endocardial AP. The combination of a q wave in V1 with a proportion of the positive QRS component in V1 V3, predicted a right endocardial AP with a 100% specificity. In case of a positive QRS sum in V2, this ‘double transition’ pattern predicted a posteroseptal right endocardial AP with 99.5% specificity and 44% sensitivity. The positive predictive value was 97%. The only false positive was a midseptal AP. In the case of a negative or isoelectric QRS sum in V2, APs were located more laterally on the tricuspid annulus. Conclusion The combination of a q wave in V1 with a double QRS transition pattern in the precordial leads is highly specific of a right endocardial AP and rules out the need for CS or left-sided mapping.

INTRODUCTION Catheter ablation (CA) for long-standing persistent atrial fibrillation (LS-AF) remains challenging. We aimed to explore whether sinus rhythm (SR) restoration and left atrium (LA) function after pretreatment with antiarrhythmic drugs (AAD's) and electrical cardioversion (ECV) predict procedural outcomes. METHODS AND RESULTS We included 100 consecutive patients with LS-AF who were treated with AAD/ECV for at least 3 months before CA. The echocardiographic LA strain during reservoir phase (LASr) was assessed after pretreatment as a marker of LA fibrosis. The recurrence was recorded for ≥1 year after the last procedure. During a 34 ± 16-month follow-up period, the single and multiple procedures and pharmaceutically assisted success rates were 40% and 71%, respectively. Patients with preprocedural SR restoration and higher LASr showed a significantly higher recurrence-free probability after the last CA (logrank P = .001 and P

We report the case of a bowel injury, which occurred after the percutaneous cryoablation (PCA) of large renal cell carcinoma (RCC). A 50-year-old man with RCC measuring 47 mm in diameter. First, we performed transarterial embolization for the tumor, followed by PCA with hydrodissection, which displaced the small intestine from the iceball. The procedure was completed without any complication on the procedural day; however, the patient complained of appetite loss and abdominal pain 2 days after PCA. Computed tomography revealed a bowel injury at the small intestine adjacent to the tumor. After 7 days, ileus tube insertion, and fasting, the patient recovered from the bowel injury and was discharged 10 days after PCA. He underwent a second PCA because of a small recurrent renal tumor 5 months after the first PCA without complications. This case indicated that a bowel injury after PCA for RCC could be treated conservatively. Keywords: Cryoablation, Renal cell carcinoma, Bowel injury, CT guided

BACKGROUND Paucity of a premature ventricular complex (PVC) during ablation procedures may occur and be associated with a lower success rate. Isoproterenol (ISP) injections are commonly used to induce PVC; however, the induced tachycardia sometimes prevents the appearance of PVC. Epinephrine (EPI) administration may be an alternative strategy to induce PVC due to its smaller effect on heart rate (HR). This study sought to examine the electrophysiological impact of EPI injection, with a stepwise induction protocol, for infrequent intraprocedural PVC. METHODS We studied 78 consecutive patients who underwent catheter ablation of idiopathic frequent PVC. If no PVC was observed at the beginning of the procedure, ISP (10 µg) was injected. If clinical PVC was not induced by ISP administration, EPI (10 µg) was injected. RESULTS Of 18 patients without PVC at baseline, ISP injection induced PVC in five patients. Of the remaining 13 patients, EPI injection successfully induced PVC in seven patients (53%). The maximum HR and increments of HR after EPI injection were significantly lower than those after ISP injection (99 ± 15 vs 137 ± 15 bpm, P = .001; 22 ± 10 vs 53 ± 12 bpm, P

Objectives This study aimed to develop a novel premature ventricular contraction (PVC) mapping method to predict PVC origins in whole ventricles by merging a magnetocardiography (MCG) image with a cardiac computed tomography (CT) image. Background MCG can noninvasively discriminate PVCs originating from the aortic sinus cusp from those originating from the right ventricular outflow tract. Methods This study was composed of 22 candidates referred for catheter ablation of idiopathic PVCs. MCG and CT were performed the same day before ablation. Estimated origins by MCG-CT imaging using the recursive null steering spatial filter algorithm were compared with origins determined by electroanatomic mapping (CARTO, Biosense Webster, Inc., Diamond Bar, California) during the ablation procedure. Radiopaque acrylic markers for the CT scan and coil markers generating a weak magnetic field during MCG measurements were used as reference markers to merge the 2 images 3-dimensionally. Results PVC origins were determined by endocardial and epicardial mapping and ablation results in 18 (86%) patients (right ventricular outflow tract in 10 patients, aortic sinus cusp in 2 patients, interventricular septum in 1 patient, near His bundle in 1 patient, right ventricular free wall in 1 patient, and left ventricular free wall in 3 patients). Estimated origins by MCG-CT imaging matched the origins determined during the procedure in 94% (17 of 18) of patients, whereas the electrocardiography algorithms were accurate in only 56% (10 of 18). Discrimination of an epicardium versus an endocardium or right- versus left-sided septum was successful in 3 of 4 patients (75%). Conclusions The diagnostic accuracy of noninvasive MCG-CT mapping was high enough to allow clinical use to predict the site of PVC origins in the whole ventricles.

【背景】頭部外傷(TBI)から数年以上の期間を経て慢性外傷性脳症や外傷後精神病などの遅発性脳障害が引き起こされることがある。TBIの慢性期には、蛋白質蓄積症、慢性炎症、脳構造変化など様々な変化が引き起こされるが、その詳細は未だ謎に包まれている。我々は、TBIによる遅発性脳障害の精神病症状が脳内タウ蓄積と関連することを報告したが、タウ病変が局所脳活動に及ぼす影響については未だ検討されていない。本研究では、TBIの長期経過例における糖代謝と認知機能障害との関係、および糖代謝とタウ蓄積との関係を検討した。 【方法】TBIの長期経過例 21名(平均47.6歳、経過年数 24.6年)、および健常被験者(平均43.2歳)に対してタウPET(11C-PBB3)、アミロイドPET(11C-PiB)、18F-FDG による糖代謝PET、MRIおよび神経心理検査を実施した。タウ蓄積、アミロイド蓄積は小脳を参照領域とするSUVR(standard uptake tissue ratio)法にて、糖代謝は白質を参照領域とするSUVR法で定量した。 【結果】健常群に比して、TBI群は皮質全体、尾状核、視床、海馬、前頭葉皮質、帯状回、小脳で18F-FDG SUVR値の有意な低下を認めた。大脳皮質全体の18F-FDG SUVR値は、MMSE、論理的記憶(遅延再生)、レイの複雑図形などのスコアと正の相関を認め、糖代謝が低下するほど認知機能障害が重度になる傾向が示された。一方、18F-FDG SUVR値とタウ蓄積量との間には正の相関が認められ、タウ凝集体による神経毒性が局所の脳活動を亢進させている可能性が示唆された。 【考察】本研究により、TBIの長期経過例において糖代謝の低下が認知機能障害の指標となることが示された。TBIによる遅発性脳障害は複合的な病態であり、個々の病態に対応したイメージングバイオマーカーを開発する必要がある。, 第43回日本生物学的精神医学会・第51回日本神経精神薬理学会 合同年会

Aims A high-density pace-mapping can depict an abrupt transition in paced QRS morphology from a poor to excellent match, unmasking the critical component of ventricular tachycardia (VT) isthmus from the entrance to exit. We sought to assess pace-mapping at multiple sites within the endo- and epicardial scars to identify the VT isthmus in patients with ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM). Methods and results Colour-coded maps correlating to the percentage matches between 12-lead electrocardiograms during VT and pace-mapping [referred to as correlation score maps (CSMs)] were analysed. We studied 115 CSMs (80 endo- and 35 epicardial CSMs) in 37 patients (17 ICM, 20 NICM). The CSM with an abrupt change (AC) in pacemap score (AC-type) on the endocardium was more frequently observed in ICM than in NICM [11/39 (28%) vs. 1/41 (2%); P = 0.001]. Among 35 CSMs that were analysed by the combined endo- and epicardial mapping, 10 (29%) CSMs exhibited non-AC-type on the endocardium; however, AC-type was present on the opposite epicardium. Although 24 (69%) CSMs did not show AC-type on both the endocardium and epicardium, 16 of them had either an excellent (>90%) or poor ( Conclusion The CSM may provide electrophysiological information to localize the endo- and epicardial VT isthmus. The absence of AC-type CSM on the endocardium, which is frequently observed in NICM, appears to indicate the sub-epicardial or intramural course of the critical isthmus.

Using 3-dimensional speckle-tracking echocardiography-derived activation imaging system, we visualized interventricular dyssynchrony in a repaired tetralogy of Fallot case with pacing-induced left ventricular dysfunction. The activation imaging system visualized interventricular dyssynchrony and resynchronization after cardiac resynchronization therapy and may be useful to assess electromechanical disturbance in complicated congenital heart diseases. (Level of Difficulty: Intermediate.), Graphical abstract, Using 3-dimensional speckle-tracking echocardiography-derived activation imaging system, we visualized interventricular dyssynchrony in a repaired…

Radiofrequency ablation at the aortic root has the potential risk of aortic regurgitation (AR).This study investigated the incidence and clinical features of iatrogenic AR after catheter ablation of idiopathic ventricular arrhythmias originating from the aortic root.We studied 45 consecutive patients with idiopathic ventricular arrhythmias originating from the aortic cusps (ACs; AC group; n = 32 [71%]) and papillary muscles (control group; n = 13 [29%]) who underwent ablation via a retrograde aortic approach and serial echocardiography before and within 24 hours after the ablation procedure. No patients had preexisting AR.After ablation, mild AR occurred in 5 AC group patients and 1 control group patient. Regurgitant flow was observed at the center of the aortic leaflets in 3 patients, the left coronary cusp-noncoronary cusp commissure in 2 patients, and both in 1 patient. No patients undergoing ablation only above the aortic valve developed AR. In AC group patients, the occurrence of AR was associated with a longer ablation time (24 ± 14 minutes vs 10 ± 5 minutes; P.01) and higher average output (36.6 ± 4.2 W vs 32.0 ± 3.2 W; P = .01). The same severity of AR still existed after 16.2 ± 3.6 months of follow-up. No patients required any additional medical management or surgical intervention.Iatrogenic mild AR after ablation in the aortic root occurred with a noticeable prevalence, which was associated with extensive ablation both above and below the ACs as well as catheter-related mechanical factors. Although it did not appear to aggravate the hemodynamic status during the mid-term follow-up, careful monitoring of AR progression should be considered.

Background: Ventricular fibrillation (VF) storm after myocardial infarction (MI) is a life-threatening condition that necessitates multiple defibrillations. Catheter ablation is a potentially effective treatment strategy for VF storm refractory to optimal medical treatment. However, its impact on patient survival has not been verified in a large population. Methods: We conducted a multicenter, retrospective observational study involving consecutive patients who underwent catheter ablation of post-MI refractory VF storm without preceding monomorphic ventricular tachycardia. The target of ablation was the Purkinje-related ventricular extrasystoles triggering VF. The primary outcome was in-hospital and long-term mortalities. Univariate logistic regression and Cox proportional-hazards analysis were used to evaluate clinical characteristics associated with in-hospital and long-term mortalities, respectively. Results: One hundred ten patients were enrolled (age, 65±11years; 92 men; left ventricular ejection fraction, 31±10%). VF storm occurred at the acute phase of MI (4.5±2.5 days after the onset of MI during the index hospitalization for MI) in 43 patients (39%), the subacute phase (>1 week) in 48 (44%), and the remote phase (>6 months) in 19 (17%). The focal triggers were found to originate from the scar border zone in 88 patients (80%). During in-hospital stay after ablation, VF storm subsided in 92 patients (84%). Overall, 30 (27%) in-hospital deaths occurred. The duration from the VF occurrence to the ablation procedure was associated with in-hospital mortality (odds ratio for each 1-day increase, 1.11 [95% CI, 1.03–1.20]; P =0.008). During follow-up after discharge from hospital, only 1 patient developed recurrent VF storm. However, 29 patients (36%) died, with a median survival time of 2.2 years (interquartile range, 1.2–5.5 years). Long-term mortality was associated with left ventricular ejection fraction P =0.014), New York Heart Association class ≥III (hazard ratio, 2.68 [95% CI, 1.16–6.19]; P =0.021), a history of atrial fibrillation (hazard ratio, 3.89 [95% CI, 1.42–10.67]; P =0.008), and chronic kidney disease (hazard ratio, 2.74 [95% CI, 1.15–6.49]; P =0.023). Conclusions: In patients with MI presenting with focally triggered VF storm, catheter ablation of culprit triggers is lifesaving and appears to be associated with short- and long-term freedom from recurrent VF storm. Mortality over the long-term follow-up is associated with the severity of underlying cardiovascular disease and comorbidities in this specific patient population.

The role of catheter ablation as an adjunct and alternative to ICD implantation is not known in patients at risk for recurrent ventricular tachycardia (VT) and sudden cardiac death (SCD) across Asia. Patients with nonischemic etiologies of cardiomyopathy, which are highly prevalent in Asia, have not been previously enrolled in randomized trials of VT ablation. To evaluate whether preemptive catheter ablation in patients with monomorphic VT and an indication for ICD implantation results in improved clinical outcomes compared to ICD implantation with standard medical therapy alone. To examine the natural history of ablation outcomes in the absence of background ICD therapy in patients that refuse randomization. The PAUSE-SCD study (NCT02848781) is a prospective, multi-center, randomized controlled trial enrolling patients with structural heart disease (EF

Brown adipose tissue (BAT) is an endocrine organ that contributes to thermogenesis and energy consumption. We investigated the effects of salt loading and surgical removal of whitened interscapular BAT (iBAT) on cardiac and adipose tissue pathology in DahlS.Z-Leprfa /Leprfa (DS/obese) rats, an animal model of metabolic syndrome (MetS). DS/obese rats were subjected to surgical removal of iBAT or sham surgery at 8 weeks of age and were provided with drinking water containing or not containing 0.3% NaCl for 4 weeks beginning at 9 weeks of age. Removal of iBAT suppressed the salt-induced exacerbation of left ventricular inflammation, fibrosis, and diastolic dysfunction, but not that of hypertension development, in DS/obese rats. Salt loading attenuated adipocyte hypertrophy but enhanced inflammation in both visceral white adipose tissue (WAT) and iBAT. Although iBAT removal did not affect visceral WAT pathology in salt-loaded DS/obese rats, it attenuated the elevation of circulating interleukin-6 levels in these animals. Downregulation of uncoupling protein-1 expression in iBAT of DS/obese rats was not affected by salt loading. Our results suggest that the conversion of iBAT to WAT-like tissue contributes to a salt-induced elevation of circulating proinflammatory cytokine levels that leads to exacerbation of cardiac pathology in this model of MetS.

Background Catheter ablation of LV summit VT can be challenging due to possible subepicardial or intramural site of origin and its close proximity to the major coronary vessels. Objective Local electrograms monitoring inside LV summit communicating vein potentially defines arrhythmogenic substrates and facilitates ablation from the adjacent anatomical structures. Results We experienced two cases of LV summit VT with epicardial local abnormal ventricular activities (Epi-LAVA) recorded from distal bipolar electrode of the 2F microcatheter in communicating vein close to the superior portion of LV summit. During sinus rhythm, Epi-LAVA displayed isolated late fractionated potentials in the first case but had initial fractionated potentials fused with terminal portion of far-field ventricular signals and late isolated potentials exhibiting 2:1 conduction in the second case. Epi-LAVA represented earliest ventricular signals during VT in both cases. Pace mapping at Epi-LAVA sites yielded single QRS morphology with excellent pacemap score and induced VT. Our strategy was to perform ablation at the facing site of Epi-LAVA aiming to eliminate the potentials transmurally. Radiofrequency (RF) energy was applied above and under the left coronary cusp opposite to Epi-LAVA sites using 3.5-mm tip open-irrigation catheter with a power of 30–35 W for 60 seconds under real-time intracardiac echocardiograhic guidance. VT was slowed and terminated in 1 second. Repeat ablation delayed and completely abolished Epi-LAVA followed by noninducibility of VT. Anatomical proximity of the left coronary cusp semilunar insertion and subepicardial or intramural site of origin possibly dictates successful ablation. Epi-LAVA from coronary vein mapping serve as a new landmark of the ablation target with a measurable procedural endpoint. Conclusion Elimination of epicardial substrates with RF energy application at the left coronary cusp can be a novel strategy for LV summit VT ablation. Funding Acknowledgement Type of funding source: None

This study sought to demonstrate a new type of verapamil-sensitive fascicular ventricular tachycardia (VT) with a reverse circuit.Left posterior fascicular ventricular tachycardia (LPFVT) is the most common form of verapamil-sensitive fascicular VT. Reverse-type LPFVT has not been reported.We searched for a reverse-type LPFVT among 242 patients with verapamil-sensitive VT from February 2006 to September 2019.Three patients had a reverse-type LPFVT (cycle lengths: 340, 360, and 340 ms). QRS configuration during VT was narrow (140, 150, and 140 ms) and exhibited rSr' morphology in VReverse-type LPFVT can occur. If common LPFVT exists, diastolic P1 during LPFVT can be a common target of ablation. If only reverse-LPFVT is inducible, the earliest ventricular activation site can be a target.