case_images: PMC11341413_01
case_images: (A) Representative 12-lead electrocardiogram. (B) Twelve-lead Holter monitor tracing. Holter showed more than 5 different RV inflow and outflow tract PVC morphologies with a total burden of 28% over 24 h. Follow-up 24-h Holter 3 months post-ablation demonstrated 6% PVC burden.
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case_images: PMC11341413_01_fcvm-11-1392186-g001.jpg
case_images: F1
case_images: The initial evaluation at our institution revealed diffuse low voltage QRS complexes on the 12-lead electrocardiogram, but no inverted T waves or epsilon waves (Figure 1A). A 12-lead Holter monitor showed 28% burden (25,000/24 h) of PVCs with more than 5 different morphologies consistent with RV inflow and outflow tract (RVOT) exits (Figure 1B).
case_images: Cine cardiac magnetic resonance balanced steady state free precession cinegraphic imaging (A) 4-chamber end-diastole, (B) 4-chamber end-systole, (C) short axis end-diastole, and (D) short axis end-systole. Imaging demonstrated mild RV enlargement (RV end-diastolic volume index 107 ml/m2, normal range 51-103 ml/m2) without dyssynchrony, akinesia, or dyskinesia; normal biventricular function (RV EF 51%, LV EF 58%), and no late gadolinium enhancement or other structural abnormality.
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case_images: PMC11341413_01_fcvm-11-1392186-g002.jpg
case_images: F2
case_images: Cardiac magnetic resonance (CMR) imaging revealed a borderline increased RV chamber size (RV end-diastolic volume indexed for body surface area 107 ml/m2, normal range 51-103 ml/m2) with normal systolic function (RVEF 51%, LVEF 58%) without dyssynchrony, akinesia, or dyskinesia, and no findings suggestive of RV or LV fibrosis, myocarditis, infarction, or late gadolinium enhancement (Figure 2).
case_images: (A) Right anterior oblique (left) and left anterior oblique (right) views of the endocardial right ventricular bipolar electroanatomic maps showing low voltage along the tricuspid annulus and RVOT. The inlet shows an area with low amplitude and fractionated local electrograms. Ablation targets at the peritricuspid and suprapulmonic areas are also shown. The focal abnormality at the mid-distal septum likely reflects an area targeted during PVC ablation procedure previously performed at another institution. (B) Right anterior oblique (left) and left anterior oblique (right) views of the unipolar voltage mapping of the right ventricle showing low voltage in the peritricuspid area and RVOT. Red and purple colors represent low and normal voltage bipolar electrograms, respectively (bipolar: <0.5 mV and >1.5 mV; unipolar: <0.5 mV and >5.5 mV). Intermediate colors represent borderline voltage as shown in the scale in the top center of the figure.
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case_images: PMC11341413_01_fcvm-11-1392186-g003.jpg
case_images: F3
case_images: Endocardial high-density substrate bipolar voltage mapping with a PentaRay multielectrode catheter (Biosense Webster, Diamond Bar, CA) demonstrated extensive abnormality with low-voltage and fractionated electrograms on the free wall peri-tricuspid region and the RVOT free wall with sparing of the septum (Figure 3). Two predominant PVC morphologies were targeted with acute success at the anterior tricuspid annulus and the anteroseptal supra-pulmonic RVOT (Figure 3).