JACC. Case reports · 2026
Premature Ventricular Complexes With 2 QRS Morphologies: Cardiac Crux Insights and an Endocardial Ablation Strategy.
Клинический случайСтатьяНазвание и аннотация: Перевод в очереди
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Vo Thai Duy, Nguyen Minh Nhut, Lin Chin-Yu
Аннотация
BACKGROUND: Premature ventricular complexes (PVCs) from the cardiac crux often have intramural or epicardial substrates, complicating localization and ablation.
CASE SUMMARY: A 53-year-old man presented with symptomatic, flecainide-refractory PVCs with a 24-hour Holter burden of 41.8%. An electrocardiogram showed frequent PVCs with 2 alternating QRS morphologies (right and left bundle branch block), both with a superior axis and subtle V1 to V2 and/or precordial differences, suggesting a single crux focus with preferential exits. Proximal coronary sinus mapping did not reveal early activation. Stepwise bilateral endocardial mapping identified the earliest basal inferoseptal activation. Standard irrigated radiofrequency catheter ablation caused only transient suppression. Half-normal saline irrigation at the earliest sites and a discrete prepotential achieved complete PVC elimination.
DISCUSSION: This case highlights idiopathic crux PVCs with variable morphologies from an intramural focus with preferential exits. A bilateral endocardial lesion-enhancement strategy may obviate epicardial access.
TAKE-HOME MESSAGES: Dual morphologies may share 1 crux focus, and bilateral endocardial mapping and lesion enhancement may be required for successful ablation.
CASE SUMMARY: A 53-year-old man presented with symptomatic, flecainide-refractory PVCs with a 24-hour Holter burden of 41.8%. An electrocardiogram showed frequent PVCs with 2 alternating QRS morphologies (right and left bundle branch block), both with a superior axis and subtle V1 to V2 and/or precordial differences, suggesting a single crux focus with preferential exits. Proximal coronary sinus mapping did not reveal early activation. Stepwise bilateral endocardial mapping identified the earliest basal inferoseptal activation. Standard irrigated radiofrequency catheter ablation caused only transient suppression. Half-normal saline irrigation at the earliest sites and a discrete prepotential achieved complete PVC elimination.
DISCUSSION: This case highlights idiopathic crux PVCs with variable morphologies from an intramural focus with preferential exits. A bilateral endocardial lesion-enhancement strategy may obviate epicardial access.
TAKE-HOME MESSAGES: Dual morphologies may share 1 crux focus, and bilateral endocardial mapping and lesion enhancement may be required for successful ablation.