Electrocardiographic and electrophysiologic features of ventricular arrhythmias originating from the right/left coronary cusp commissure

Background: Ventricular arrhythmias are known to originate from the aortic sinus of Valsalva. Objective: The purpose of this study was to identify the characteristics associated with ventricular arrhythmias originating from the right coronary cusp-left coronary cusp (RCC-LCC) commissure. Methods: Thirty-seven consecutive patients with ventricular arrhythmias originating from the aortic cusp region were studied. Intracardiac echocardiography and electroanatomic mapping were used to define coronary cusp anatomy and catheter position. Ventricular arrhythmias from the RCC-LCC commissure were compared with ventricular arrhythmias originating from other sites in the aortic cusp region. Results: Nineteen (51%) ventricular arrhythmias had an anatomic origin at the RCC-LCC commissure. Eighteen ventricular arrhythmias originated from other aortic cusp sites (4 right cusp, 7 left cusp, 3 left ventricular endocardium, 4 left ventricular epicardium anterior to aortic valve). A QS morphology in lead V₁ with notching on the downward deflection was present in 15 of 19 ventricular arrhythmias originating from the RCC-LCC commissure compared to 2 of 18 ventricular arrhythmias from other aortic cusp sites (P <.01). At the site of earliest activation, 13 of 19 patients with RCC-LCC ventricular arrhythmias had late potentials in sinus rhythm compared to 1 of 18 ventricular arrhythmias from other aortic cusp sites (P <.01). The site of successful ablation was confirmed to be above the aortic valve plane in 15 (79%) of 19 patients with RCC-LCC ventricular arrhythmias. Conclusion: RCC-LCC aortic cusp ventricular arrhythmias are common and have a QS morphology in lead V₁ with notching on the downward deflection with precordial transition at lead V₃. In the majority of cases, the site of successful ablation has late potentials in sinus rhythm.