Anatomical Approach from Aortic Sinus of Valsalva for Para-Hisian Premature Ventricular Contractions: Safety and Outcomes

BACKGROUND: The optimal ablation strategy for para-Hisian premature ventricular contractions (PVCs) remains uncertain because of the risk of conduction system injury. OBJECTIVE: To evaluate the safety and outcomes of catheter ablation for para-Hisian PVCs, with particular focus on the efficacy and safety of an anatomical approach from the coronary cusps. METHODS: We retrospectively analyzed 114 patients undergoing para-Hisian PVC ablation. Acute success, long-term clinical success (≥80% PVC reduction), conduction system injury, and ablation sites were assessed. RESULTS: Acute procedural success was achieved in 89 patients (78%). However, long-term clinical success was achieved in only 52% of patients with acute success. Coronary cusp ablation was attempted in total of 35 patients (31%) and was performed significantly more frequently in clinical success cases than in clinical failures (38% vs. 7%, P=0.005). Among the 35 patients undergoing cusp ablation, PVCs were terminated in 49% (17/35), while transient suppression or morphological change of PVCs was observed in an additional 31% (11/35). Predictors of successful cusp ablation included earlier activation at the cusp and close anatomical proximity between the cusp and the earliest activation site in the His bundle region. Conduction system injury occurred in 31 patients overall, predominantly during His bundle region ablation, with only one event occurring during cusp ablation. CONCLUSION: Coronary cusp ablation incorporated into a stepwise, multi-site ablation strategy may be associated with better procedural outcomes for para-Hisian PVC ablation without compromising safety. Earlier activation and close anatomical proximity between the para-Hisian site and the cusp region predict successful ablation using this approach.