Three-dimensional cardiac CT integration for procedural guidance in LVOT-PVC ablation: a targeted clinical approach based on electrocardiographic and patient-specific criteria

Ablation of ventricular premature complexes (PVCs) originating in the ventricular outflow tract (PVCs-OT) is challenging, particularly at left ventricular outflow tract (LVOT) sites. Although intracardiac ultrasound can aid procedural guidance, it involves additional vascular access, increased manipulation, and higher costs. Integrating pre-procedural three-dimensional (3D) computed tomography (CT) reconstructions offers an alternative to enhance PVC-LVOT ablation.

To evaluate the efficacy and safety of incorporating 3D CT imaging in PVC-OT ablation guided by electrocardiographic and patient-specific criteria, aiming to optimise procedural success and minimise risks.

Patients referred for PVCs-OT ablation from January 2021 onward were included. Our pre-ablation protocol for patients with PVCs showing transition ≤ V3 includes CT scanning within 24 hours of the procedure. Ablation was performed through single femoral access using only an ablation catheter (SmartTouch, Biosense). Retroaortic electroanatomic mapping was applied in cases with transition <v3,<50 years). Ablation was delivered at 40W and an f-index of 450-500, with a minimum 1 cm distance from coronary arteries, as determined by CT. Success at 1-year follow-up was defined as >80% PVC reduction on Holter.

Seventy-two patients were included, 64% with transition ≤ V3. Pre-procedural CT was performed in 68% of cases. The LVOT was the most frequent site of origin (63%). Acute success was achieved in 96% of cases, with 85% success at 1-year follow-up (Table 1). Mean procedure and fluoroscopy times were 66 ± 33 minutes and 2.3 ± 3.8 minutes, respectively. No procedural or vascular complications were noted. In transition ≤ V3 cases, left-sided origins were found in 87%, with a mean procedure time of 77 ± 31 minutes and fluoroscopy of 3 ± 4 minutes. Acute and 1-year success rates were 93% and 82%, respectively. All patients with transition at V3 and right-sided origins did not .

The integration of 3D CT in PVCs-OT ablation, guided by electrocardiographic and clinical criteria, demonstrates high efficacy and safety in patients with suspected left-sided PVC origins, providing a streamlined and effective approach to LVOT-PVC ablation.

PVC ablation approach.