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\begin{document}

\title{Use of Computational ECG Mapping to Guide Successful Surgical
Cryoablation of a PVC Originating near an Intramural Anomalous Coronary
Artery}



\author[1]{Candace L. Jackson}%
\author[1]{David Krummen}%
\author[1]{Matthew Carazo}%
\author[1]{Gregory Feld}%
\author[1]{Jonathan Artrip}%
\author[1]{Gordon Ho}%
\affil[1]{University of California San Diego Health System}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Introduction:} Premature ventricular contractions (PVC) and
anomalous coronary arteries have not been previously associated.
\textbf{Methods:} 40-year-old female presented with symptomatic PVCs.
Pre-ablation imaging revealed an anomalous right coronary artery (RCA)
originating from the left coronary cusp with an interarterial,
intramural course. Novel ECG mapping localized PVCs to the septal right
ventricular outflow tract (RVOT) near the anomalous RCA.
\textbf{Results:} Surgical PVC cryoablation at the endocardial RVOT was
performed, followed by unroofing surgery, with \textless{}1\% PVCs at 2
years. \textbf{Conclusion}: This is the first report associating PVCs to
the site of an anomalous RCA. Surgical cryoablation during unroofing
surgery was guided by novel ECG mapping.%
\end{abstract}%



\sloppy


\textbf{Introduction:}

Anomalous coronary arteries are rare. A malignant course occurs when the
anomalous coronary artery takes an interarterial course between the
aorta and pulmonary artery (with or without an intramural segment) and
is associated with ischemia and an increased risk of sudden cardiac
death due to extrinsic compression.\textsuperscript{1-5} Although the
occurrence of ventricular fibrillation (VF) has been reported in
patients with malignant anomalous coronary
arteries,\textsuperscript{6}ventricular arrhythmias have not been
previously localized to the site of an anomalous coronary artery.

We report for the first time the association of a premature ventricular
contraction (PVC) originating near an anomalous right coronary artery
(RCA), and the successful use of a novel computational mapping algorithm
based solely on a standard 12-lead electrocardiogram (ECG) to guide
concomitant surgical PVC ablation during coronary artery unroofing.

\textbf{Case Report:}

A 40-year-old female presented with symptomatic palpitations and was
found to have 8\% burden of monomorphic PVCs of inferior axis left
bundle branch block (LBBB) morphology (\textbf{Figure 1A} ) despite
titration of metoprolol and flecainide doses. During workup for PVC
ablation, cardiac computed tomography (CT) revealed an anomalous RCA
originating from the left sinus of Valsalva with an interarterial,
intramural course (\textbf{Figure 1B} ). Given the intramural course,
she was referred for surgical unroofing of the anomalous
RCA\textsuperscript{7} and concomitant surgical cryoablation of the PVC.

A novel peri-operative surgical PVC ablation workflow was designed
utilizing a non-invasive 12-lead ECG based mapping system (vMap, Vektor
Medical Inc, Carlsbad, CA). In the outpatient clinic, the patient's PVCs
were captured using a standard 12-lead ECG acquisition system (Muse, GE
Medical) and digitized using custom software. The ECG data file was
imported into the computational ECG mapping system. Patient
characteristics (absence of scar or left ventricle dilation) were
recorded, and the PVC exit site was localized to the septal right
ventricular outflow tract (RVOT) underneath the pulmonic valve, near the
course of the anomalous RCA. The site of origin was visualized on a 3D
model (\textbf{Figure 1C} ) within 36 seconds of total mapping time.

Subsequently, the patient was placed under general anesthesia and
underwent sternotomy. She was initiated on cardiopulmonary bypass, and
the heart was arrested. An incision was made in the pulmonary artery,
and 3 cryoablation lesions using a cryoablation probe of 90 second
durations to -50\selectlanguage{ngerman}° Celsius were placed at the PVC exit site localized to
the septal RVOT (\textbf{Figure 1D} ). The pulmonary artery incision was
then sutured. Coronary artery unroofing of the intramural RCA was
performed, after which the heart was re-perfused, and the patient was
weaned off bypass uneventfully.

Post-operatively, the patient recovered without any complications. There
were no PVCs on telemetry, and she was discharged from the hospital in 4
days. Her palpitations and PVCs were eliminated durably, with event
monitors showing \textless{}1\% PVC burden at 2-year follow-up.

\textbf{Discussion:}

Anomalous coronary arteries with a malignant course are associated with
an increased risk of arrhythmias and sudden cardiac
death,\textsuperscript{4-6} though ventricular arrhythmias have not been
previously localized to the site of an anomalous coronary artery. This
is the first report associating a PVC to the site of an anomalous,
interarterial, intramural coronary artery.

PVC localization and surgical cryoablation were guided by the use of a
novel ECG mapping system. ECG data are imported into the computational
mapping system that then localizes and integrates the highest
probabilistic location for the PVC focus onto the patient's CT 3D
reconstruction model. This algorithm is based on forward-solution
computational simulation libraries of arrhythmias including PVCs
originating from sites around the heart with or without scar. The
simulation libraries are based on 3D finite element models of monodomain
cardiac action potential propagation using the Continuity simulation
environment. The models consist of detailed descriptions of cardiac
geometry, myofiber orientation, and scar. The simulation library
incorporates \textgreater{}1 million simulated arrhythmia cycles.

There are many advantages to this technique. This method is less time
consuming than traditional invasive catheter-based mapping and is easy
to incorporate into any clinical workflow, including mapping in an
outpatient clinic using standard widely-available ECG equipment. It has
been shown to be a rapid and accurate technique, with a recent blinded
multicenter clinical trial showing segmental accuracy of 100\%
{[}96-100\%{]} and spatial accuracy of 11mm {[}5-22mm{]} for PVC
localization.\textsuperscript{8}

The use of a non-invasive 12-lead ECG based mapping system to
successfully guide surgical ablation of ventricular arrhythmias is a
novel approach that can expand the indications for concomitant
arrhythmia ablation during cardiac surgery for other indications. The
familiarity of the 12-lead ECG to all physicians including cardiac
surgeons is attractive as it can be easily integrated into any clinical
pre-procedural workflow.

\textbf{Conclusion:}

For the first time, we describe the association of a PVC to the site of
an anomalous RCA and the use of a novel arrhythmia ECG mapping algorithm
to localize and guide successful concomitant surgical cryoablation
during coronary artery unroofing surgery, resulting in long-term
elimination of PVCs.

\textbf{References}

1. Cheezum MK, Liberthson RR, Shah NR, et al. Anomalous Aortic Origin of
a Coronary~Artery From the Inappropriate~Sinus of~Valsalva. \emph{J Am
Coll Cardiol} . Mar 28 2017;69(12):1592-1608.
doi:10.1016/j.jacc.2017.01.031

2. Kragel AH, Roberts WC. Anomalous origin of either the right or left
main coronary artery from the aorta with subsequent coursing between
aorta and pulmonary trunk: analysis of 32 necropsy cases. \emph{Am J
Cardiol} . Oct 01 1988;62(10 Pt 1):771-7.
doi:10.1016/0002-9149(88)91220-9

3. Cheitlin MD, De Castro CM, McAllister HA. Sudden death as a
complication of anomalous left coronary origin from the anterior sinus
of Valsalva, A not-so-minor congenital anomaly. \emph{Circulation} . Oct
1974;50(4):780-7. doi:10.1161/01.cir.50.4.780

4. Brothers J, Carter C, McBride M, Spray T, Paridon S. Anomalous left
coronary artery origin from the opposite sinus of Valsalva: evidence of
intermittent ischemia. \emph{J Thorac Cardiovasc Surg} . Aug
2010;140(2):e27-9. doi:10.1016/j.jtcvs.2009.06.029

5. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of
congenital coronary artery anomalies with origin from the wrong aortic
sinus leading to sudden death in young competitive athletes. \emph{J Am
Coll Cardiol} . May 2000;35(6):1493-501.
doi:10.1016/s0735-1097(00)00566-0

6. Anantha Narayanan M, DeZorzi C, Akinapelli A, et al. Malignant Course
of Anomalous Left Coronary Artery Causing Sudden Cardiac Arrest: A Case
Report and Review of the Literature. \emph{Case Rep Cardiol} .
2015;2015:806291. doi:10.1155/2015/806291

7. Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC Guideline for
the Management of Adults With Congenital Heart Disease: A Report of the
American College of Cardiology/American Heart Association Task Force on
Clinical Practice Guidelines. \emph{Circulation} . Apr 02
2019;139(14):e698-e800. doi:10.1161/CIR.0000000000000603

8. Krummen DE, Villongco CT, Ho G, et al. Forward-Solution Noninvasive
Computational Arrhythmia Mapping: The VMAP Study. \emph{Circ Arrhythm
Electrophysiol} . Sep 2022;15(9):e010857. doi:10.1161/CIRCEP.122.010857\selectlanguage{english}
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