Incidence of Worsening Aortic Regurgitation After Mapping and Ablation in the Aortic Cusps

Ventricular arrhythmias from the aortic cusps (ACs) represent a subset of left ventricular outflow tract arrhythmias. Although ablation in this region can be highly effective, concerns persist regarding aortic valve injury and iatrogenic aortic regurgitation (AR). Contemporary data on AR incidence after AC mapping/ablation remain limited.

This study sought to determine the incidence, severity, and clinical significance of AR in a multicenter cohort after mapping and/or radiofrequency ablation in the ACs or commissures.

We retrospectively analyzed patients at 4 high-volume centers (2015-2024) who underwent AC/commissural mapping and/or ablation for ventricular arrhythmia and had paired preprocedural and postprocedural transthoracic echocardiograms (TTEs). AR was graded by using standardized criteria; procedure-related AR was defined as ≥2-grade worsening or new ≥moderate AR.

Among 290 patients, 208 (218 procedures) had complete paired TTEs. Baseline AR was absent in 81% and mild in 18%. Retrograde aortic access was used in 94%, and 77% underwent radiofrequency ablation within the cusps. Clinically significant AR (≥2-grade worsening or new moderate AR) occurred in 2 procedures (0.9%), both representing progression from preexisting mild-to-moderate AR, with one of the patients having a bicuspid valve. New mild AR (1-grade increase from none to mild) occurred in 26 procedures (11.9%). Among 14 with additional follow-up imaging (median 320 days after first postprocedural TTE), AR resolved in 8 (57%) and remained mild in 6 (43%). No patient required valve intervention.

Significant AR occurred in approximately 1% after AC mapping/ablation. New mild AR developed in 12.5% and improved in more than one-half during follow-up. No valve interventions were required, supporting the safety of cusp and commissural ablation at experienced centers.