An alternative under-valve approach to ablate right-sided accessory pathways

Right-sided accessory pathway (RAP) ablation is sometimes challenging.Our study aimed to demonstrate an alternative ablation approach to RAPs under the tricuspid valve, especially when the conventional ablation attempts at the atrial side failed.Twelve patients with RAPs were enrolled, 8 of whom had previously failed ablation. With the help of a long sheath, the under-valve approach was attempted in 3 patients during tachycardia, in 2 patients during ventricular pacing, and in 7 patients during sinus rhythm. Three-dimensional electroanatomic mapping was performed in 3 patients during their repeat procedures.The acute outcomes of the procedures in all patients were successful. Patients were free of tachycardia or recurrence of accessory pathway conduction during a median follow-up of 12.5 months (range 7-45 months). No complications were found during the procedure or follow-up period.Radiofrequency ablation under the tricuspid valve to eliminate RAPs is feasible because of its stable contact and the accurate ablation of the ventricular insertion site. It provides an alternative approach to tough RAP ablation.