Recurrence of RVOT PVCs with a marked shift of its exit point. Gradual elimination of arrhythmogenic focus by multisite approach

We present a case of recurrent outflow tract arrhythmia despite repeated ablations. Premature ventricular contractions (PVCs) morphology suggested a right-sided focus. However, electrograms preceding PVCs were recorded from the right and left outflow tracts, distal coronary sinus, and right sinus of Valsalva. Arrhythmia was eliminated after radiofrequency (RF) applications delivered from different sites. We conclude that, in patients with recurrent outflow tract PVCs, mapping all the sites mentioned above may be necessary to find the earliest activation site and carry out successful ablation. In some patients, RF applications from multiple sites may be necessary to completely eliminate arrhythmia.