HANDS ON
Ablation above the semilunar valves: When, why, and how?
Part II
Mahmoud Suleiman, MD, Samuel J. Asirvatham, MD
From the Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
In this two-part series on arrhythmias occurring above
the semilunar valve, we discuss the relevant underlying
anatomy and the technique for mapping and ablation above
the aortic and pulmonic valve. In part I, we focused on
ventricular arrhythmias, and in this paper (part II), we dis-
cuss the anatomy and present knowledge of the substrate
mapped and ablated above the aortic valve for atrial tachy-
cardia in certain unusual accessory pathways. The back-
ground anatomy of the aortic valve has been discussed in
part I of this series, to which the reader is referred. Here we
discuss the detailed anatomy of the aortic cusps relevant for
atrial tachycardia and atrioventricular bypass tracts. Repre-
sentative cases of these supravalvar arrhythmias are pre-
sented, and an approach for safe and effective ablation
above the aortic valve to eliminate atrial tachycardia and
bypass tracts in this location is then outlined.
Atrial tachycardia ablated above the aortic
valve
The aortic valve is related anatomically to atrial tissue at
specific sites. The noncoronary cusp (NCC) is immediately
adjacent to the interatrial septum, whereas the right atrial
appendage and the superior vena cava (SVC)/right atrial
junction may overlie portions of the right coronary cusp
(RCC). The most likely site for ablating atrial tachycardias
above the aortic valve is in the NCC, and understanding the
exact anatomy of this cusp is important when approaching
supravalvar atrial tachycardia ablation. The NCC is the most
posterior of the three aortic cusps. The most anterior portion
of this cusp is the commissure with the RCC. As noted, this
is the location of the membranous septum at which the His
bundle is located. Thus, mapping or ablation in the NCC
is unlikely to record a His bundle electrogram or ablate this
structure. However, as the fast pathway and anteroseptal
atrial myocardium are posterior to the His bundle, a catheter
KEYWORDS Atrial tachycardia; Anatomy; Radiofrequency ablation; Electro-
physiology; Coronary arteries; Accessory pathway; WPW (Heart Rhythm
2008;5:1625–1630)
Address reprint requests and correspondence: Samuel J. Asirvatham,
M.D., Division of Cardiovascular Diseases, Associate Professor of Medi-
cine, Mayo Clinic College of Medicine, 200 First Street Southwest, Roch-
ester, Minnesota 55905. E-mail address: asirvatham.samuel@mayo.edu.
1547-5271/$ -see front matter © 2008 Heart Rhythm Society. All rights reserved.
placed in the rightward portion of the NCC will map and
potentially ablate these structures. Posteriorly, as well as to
the left, portions of the NCC and the anterior portion of the
interatrial septum lie in close proximity. Successful map-
ping and ablation of supravalvar atrial tachycardias require
an accurate understanding of the anatomy, interpretation of
aortography, intracardiac ultrasound images, and apprecia-
tion of the nuances of normal and abnormal electrograms
found in the coronary cusps to safely ablate these tachycar-
dias without damage to the nearby conduction system.
Salient electrophysiological issues with
supravalvar atrial tachycardia ablation
Electrograms in the NCC
Because of the fairly thick and immediately adjacent atrial
myocardium of the atrial septum, large atrial electrograms
that appear to be relatively near field (thin valve tissue) are
routinely found when mapping the NCC. In patients with
atrial tachycardia arising from this region, however, often
fractionated (but near-field) electrograms that precede the
larger atrial electrograms are found.1,2 The possible basis
for these electrograms includes atrial myocardium being
found in the NCC, abnormal adjacent atrial septal myocar-
dium, or electrograms related to the valve tissue itself.
Although the exact nature of these electrograms is un-
known, their recognition during mapping and understanding
the need to target these electrograms are essential when
ablating NCC atrial tachycardia. If, when mapping, a large
ventricular electrogram or His bundle recording is found, it
is likely that the catheter is in the RCC. However, variable
anatomy in which the NCC is somewhat rightward of its
usual location may be responsible. Conversely, large atrial
electrograms may sometimes be found when mapping the
RCC. On first observation, this appears counterintuitive
since the RCC is displaced much more anteriorly and in
relation to the right ventricular outflow tract (RVOT), and
thus one would not expect an atrial electrogram. However,
atrial electrograms may be found in this location because of
the overlying right atrial appendage. When mapping the
RCC more distally (cephalad), the medial aspect of the SVC
is also immediately adjacent.3 Thus, as a generalization, one
expects to find a large atrial electrogram when the catheter
is located in the NCC and little or no atrial electrograms
doi:10.1016/j.hrthm.2008.04.020
1626 Heart Rhythm, Vol 5, No 11, November 2008

anterior tricuspid valve and right atrial appendage tachycar-

Figure 1 The 12-lead ECG of atrial tachycardia that was eventually
ablated in the NCC of the aortic valve. Note the terminal positive P wave
in lead V1 and the narrow but positive/isoelectric P wave in the inferior
lead. The apparently short P-R interval is sometimes noted with atrial
tachycardia arising in supravalvar locations.
with large ventricular electrograms when mapping the RCC,
but the electrophysiologist should be aware of the nuances
resulting from variation in anatomy and the overlying ad-
jacent structures.
Clues for atrial tachycardia origin above the valve
Since the number of cases reported in the literature is fairly
few, clinically distinct features of cuspal atrial tachycardias
are unknown. Both automatic tachycardia in structurally
normal hearts and tachycardia associated with atrial fibril-
lation have been described as arising from this location. The
electrocardiogram (ECG; Figure 1) typically shows fairly
narrow P waves that tend to be positive in V1 (whereas
dias are typically all negative in V1).4
When mapping (Figures 2– 4), relatively simultaneous
activation of the His bundle, fast pathway, septal mitral
annulus, and superior ostial coronary sinus regions is seen.
With these anatomically disparate sites being activated at
the same time, consideration of a deep myocardial focus in
the anterior portion of the interatrial septum is often made.
If the potential for successful ablation in the NCC is not
appreciated, then either high-energy ablation on the right
septum with risk of atrioventricular (AV) block or abortion
of the procedure is often done. When the catheter is placed
in the RCC, fractionated but near-field electrograms that
precede the previously earliest but simultaneously activated
areas by ⱖ20 ms and often ⱖ40 ms are seen. Ablation in the
NCC as long as the catheter is positioned and directed in a
straight posterior manner or leftward manner will not dam-
age the conduction system. Ablation near the commissure
with the RCC may injure the fast pathway, and thus cryoa-
blation should be considered. Another important clue is the
finding of far-field electrograms on the right interatrial sep-
tum just behind the superior portion of the tendon of Todaro
that precede local activation (the near-field electrogram) by
20 – 40 ms. This should also alert the operator to the pres-
ence of either an NCC atrial tachycardia or a septal mitral
annular tachycardia.
Left coronary cusp (LCC)/mitral annular
tachycardia
Because of the aortic mitral continuity, the LCC does not
usually have an immediate anatomic relation to atrial or
ventricular myocardium. However, some patients have
atrial tachycardia (with or without atrial fibrillation) for

Figure 2 Fluoroscopic images (left panel: left anterior oblique; right panel: right anterior oblique) of catheter positions for ablation of the tachycardia
shown in Figure 1. The ablation catheter (Abl) is shown to be leftward of the His bundle catheter in the left anterior oblique projection and is posterior (near
the proximal electrodes) to the His bundle catheter in the right anterior oblique projection. This is the typical fluoroscopic location of the NCC. The
electrograms obtained when mapping in such a location will typically show a large atrial electrogram with or without a fractionated component and a
relatively small ventricular electrogram (see text for details). TA ⫽ tricuspid annulus; RV ⫽ right ventricle; His ⫽ His bundle recording catheter; CS ⫽
coronary sinus; hRA ⫽ high right atrial mapping catheter; Abl ⫽ ablation catheter retrograde access.
Suleiman and Asirvatham Ablation above the Semilunar Valves: II 1627

Figure 3 Intracardiac electrograms during atrial tachycardia while mapping in the NCC of the aortic valve with the ablation (ABL d) catheter. The local
electrogram recorded when mapping in the NCC (ABL d) precedes the onset of the P wave and the atrial electrograms on the His bundle region by at least
34 ms. Pacing without capture is being attempted from the ablation catheter at low output (see arrow). In this case, only high-output pacing could result in
atrial capture, suggesting that this ablation site likely offered a simple vantage point in the NCC to ablate atrial tissue of the interatrial septum rather than
the supravalvar myocardium itself being the arrhythmogenic substrate (see text for details). P1 ART ⫽ arterial monitor; II, V1 ⫽ surface ECG leads; RVa ⫽
right ventricular apex; HRA ⫽ high right atrium; HIS 1– 4; His bundle recordings distal-proximal; IS 1, 2–19, 20 ⫽ cavotricuspid isthmus and free wall
recording electrodes distal-proximal; CS 1, 2–19, 20 ⫽ coronary sinus electrograms distal-proximal; ABL d ⫽ distal ablation electrode; ABL ⫽ proximal
ablation electrode. The arrow points to pacing stimulus artifact.

which successful ablation is on the anteroseptal mitral an-
nulus or within the LCC. The valvar-atrial tachycardias
likely arise from myocardium that has exceptionally per-
sisted from in utero development on the aortic mitral con-
tinuity. Simultaneous mapping with a transseptal approach
and placement of the catheter on the mitral annulus antero-
septally and via a retrograde approach in the LCC when
comparing the electrograms (near-field earliest electrogram
determination) will allow identification for the best site for
ablation (Figure 4).
Ablation for accessory pathway above the
semilunar valve
Atrioventricular bypass tracts may occur anywhere along
the atrioventricular valve annuli.5 However, because of the
positioning of the aorta, pathways are exceedingly rare in
the anteroseptal portion of the mitral annulus (region of the
aortic mitral continuity). Occasionally, pathways have been
described in the left anteroseptal region and have been
variously described as trigone pathways, left anteroseptal
pathways, or supravalvar aortic pathways.6,7 Atrioventricu-
lar accessory pathways have been ablated above the aortic
valve.8
Aortic valve–related pathways
Supravalvar pathways may connect either the left atrium or
the interatrial septum to either the left or right ventricles.
The pathways may course in a long circuitous manner
through the central fibrous body, skirting around the aortic
annulus, or involve the myocardium above the aortic valve
itself. When skirting around the annulus, the cusp simply
provides a stable vantage point to place the catheter and
ablate these trigone pathways.9 Because the atrial myocar-
dium is in closest proximity to the NCC, another potential
route for these unusual pathways is from the interatrial
septum to the NCC and from there either to the ventricular
myocardium above the RCC to the overlying RVOT (Figure
5) or inferiorly from the supravalvar ventricular myocar-
dium into the left ventricular outflow tract (LVOT). Recog-
nition of these pathways can be difficult as they are often
misdiagnosed as right anteroseptal pathways with unneces-
sary potential damage to the conduction system with at-
tempts at ablation. Clues to such pathway origin will include
1628 Heart Rhythm, Vol 5, No 11, November 2008

Figure 4 Sequential mapping with a roving catheter (Mapd) defines the site of earliest atrial activation during atrial tachycardia. Coronary sinus (CS)
ostium: The near-field electrogram that is simultaneous with the proximal CS recording and the atrial electrograms on the His catheter (HBEp) is found. Near
FP: Mapping just posterior to the tendon of Todaro finds activation slightly earlier than the His bundle, but again, multiple sites show simultaneous recordings.
MV annulus 9:00: Mapping on the septal mitral annulus records an atrial electrogram, again about as early as other recorded sites and far field in nature. RCC:
Eventually, mapping at the junction of the RCC and NCC of the aortic valve finds a fragmented atrial electrogram far ahead (60 ms) of recorded atrial
activation at other sites including the His bundle region and proximal CS. Multiple early sites along the annulus on the right and left are often a clue to an
aortic cusp origin for atrial tachycardia. HBEp ⫽ His bundle proximal; HBEd ⫽ His bundle distal; Mapp ⫽ proximal mapping electrode; Mapd ⫽ distal
mapping electrode; CSp ⫽ coronary sinus proximal; CSd ⫽ coronary sinus distal.

1. Earliest ventricular electrogram during sinus rhythm or
atrial pacing with preexcitation appears far field on the
right septum.7
2. With retrograde conducting pathways, during ortho-
dromic reciprocating tachycardia (ORT) or ventricular
pacing, the earliest electrogram may be simultaneously
recorded on the His bundle region, right midseptum, left
midseptum, and right anterior tricuspid annular region.
3. Fragmented but near-field signal representing the path-
way potential may be recorded only in the aortic cusps
themselves.7,9
Pulmonary valve–related pathways
Because of the anatomic proximity of the left atrial append-
age anteriorly, the potential for bypass tracts connecting the
left atrial appendage with ventricular myocardium (LVOT
or RVOT exists) may be one variant of an appendage
pathway.9
Precautions with regard to the coronary arterial system
and in avoiding conduction system damage are similar
when targeting accessory pathways as mentioned above
for supravalvar ventricular and atrial arrhythmia abla-
tion.
Approach to supravalvar tachycardia ablation
The approach to supravalvar ablation starts with a clear
understanding of the anatomy of the aortic cusps and the
pulmonary valves. The ablationist should be clear as to what
the normal anatomical neighbors (atrial, ventricular, or
both) are for each of the aortic cusps and the anterior and
posterior surfaces of the pulmonic valve (Table 1). In ad-
dition, knowledge of the expected electrograms when map-
ping above the valve with or without arrhythmogenic sub-
strates being located at those locations should be made
familiar.
Suleiman and Asirvatham Ablation above the Semilunar Valves: II 1629

Figure 5 A: Diagram of a right anterior oblique view of the heart showing various methods of mapping or ablating arrhythmogenic substrate near the His
bundle. Anteroseptal accessory pathways, for example, may be best approached with a catheter antegrade on the right side “above” the valve or curved under
the septal leaflet of the tricuspid valve. A near identical site can be mapped for ablation at the junction of the RCC and NCC of the aortic valve as well.
B: When premature ventricular complex (PVCs) or accessory pathways have been localized to the left anteroseptal region, ablating either through transseptal
or retrograde aortic approach with the catheter curled under the aortic valve region may be less likely to create inadvertent AV conduction block during energy
delivery. Note the difference in distance to the conduction system (yellow) between the catheter in the RCC and prolapsed into the LVOT (see text).

The fluoroscopic anatomy and intracardiac ultrasound cific understanding of proximate sensitive structures (arter-
determination of each aortic cusp and the exact location of ies, conduction system) should also be thoroughly under-
the pulmonary valve should be made familiar as well. Spe- stood.

Table 1 Supravalvar arrhythmias—anatomic correlates

Valve/cusp Atrial relation Ventricular relation Electrograms recorded Relevant arrhythmia

NCC of aortic valve
RCC
LCC
Pulmonary valve anteriorly
Pulmonary valve posteriorly
Immediate anterior neighbor None directly Large atrial electrograms with Atrial tachycardia; accessory
of the interatrial septum fragmented near-field pathways traversing the NCC
(Figure 1, Part 1) electrograms during tachycardia
Overlying right atrial Posterior infundibular portion of RVOT Large ventricular electrogram Ventricular tachycardia; vantage
appendage and SVC RA more posteriorly atrial point for posterior RVOT;
junction electrograms from overlying supravalvar myocardium; atrial
appendage; His bundle tachycardia posteriorly;
electrograms at RCC/NCC accessory pathway traversing
commissure the cusp
Typically none unless aortic Typically none unless fibers in aortic Far-field ventricular electrogram Ventricular tachycardia
mitral continuity has mitral continuity and extending with atrial electrograms
myocardial fibers above the LCC posteriorly
Overlying left atrial Left ventricular myocardium inferiorly Large ventricular electrogram, Ventricular tachycardia; accessory
appendage and continuity with RVOT possibly small far-field atrial pathway connecting to the
electrogram from appendage infundibulum
proximity
Portion of anterior left RCC lies posteriorly and on the right Large ventricular electrogram, Ventricular tachycardia
atrium and possibly a with the LCC and left main spikes or near-field signals
second posterior lobe of coronary artery immediately distinct from nearby ventricular
left atrial appendage posterior to the posterior activation
supravalvar pulmonary artery
1630
The typical clues based on ECG and during mapping
(simultaneous early activation sites around the anatomic
location of a coronary cusp or far-field activation before
near-field activation on right anteroseptal mapping) should
all alert the electrophysiologist to the need for mapping and
possible ablation in a supravalvar location.
Knowing the limitations with pace mapping and distin-
guishing between supravalvar electrograms that are arrhyth-
mogenic versus those that are passively activated (by-
stander) will allow the operator to plan an exact approach of
ablation (isolation versus targeting selected signals), maxi-
mizing the chance for ablation success yet making the risk
of collateral damage with ablation minimal.
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