151
|
Broad QRS Tachycardias. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
152
|
Abstract
Idiopathic ventricular tachycardia (VT) is an uncommon form of VT that is seen in patients without structural heart disease. It is commonly seen in young patients and usually has a benign course. Recent studies have delineated the mechanisms and anatomical locations of this form of VT. Recognition of various forms of idiopathic VT based on characteristic QRS morphology from the 12-lead electrocardiogram (ECG) has important prognostic and therapeutic implications. The understanding of the mechanisms of idiopathic VT has led to the use of specific antiarrhythmic drugs targeting particular arrhythmias. Recent technological advances in the field of mapping and catheter ablation have led to a suitable alternative to drug therapy with a very high cure rate. This review describes the clinical features, ECG recognition, and management of idiopathic monomorphic VT.
Collapse
|
153
|
Shin SY, Joo HJ, Kim JH, Jang JK, Park JS, Kim YH, Lee HS, Choi JI, Lim HE, Kim YH. Epicardial Conduction Properties and Electrocardiographic Characteristics of Premature Ventricular Complexes or Ventricular Tachycardias That Originate at the Aortic Cusp. Korean Circ J 2007. [DOI: 10.4070/kcj.2007.37.12.616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Seung-Yong Shin
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Hyung-Joon Joo
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Ji-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Jin-Kun Jang
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Jae-Seok Park
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Yong-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Hyun-Soo Lee
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Hong-Euy Lim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Anam Hospital, Seoul, Korea
| |
Collapse
|
154
|
Kaseno K, Tada H, Ito S, Tadokoro K, Hashimoto T, Miyaji K, Naito S, Oshima S, Nogami A, Taniguchi K. Ablation of Idiopathic Ventricular Tachycardia in Two Separate Regions of the Outflow Tract: Prevalence and Electrocardiographic Characteristics. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30 Suppl 1:S88-93. [PMID: 17302726 DOI: 10.1111/j.1540-8159.2007.00613.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Few studies have clarified the prevalence and characteristics of idiopathic outflow tachycardia (OT-VT) with an altered QRS morphology after radiofrequency catheter ablation (RFCA), requiring additional RFCA applications at a different portion of the outflow tract (OT) to abolish the OT-VT. Among 344 patients (97 VTs and 247 premature ventricular contractions), 12 (3.5%; VTs-7, PVCs-5; 6 women) had dynamic QRS morphology changes following the RFCA, requiring additional RFCA applications at a different portion to abolish the OT-VT. In 8 of 12 patients (67%), this phenomenon occurred following RFCA at right (RVOT; n = 7) or left ventricular (LVOT; n = 1) endocardial sites of the OT: The second OT-VT was consistently associated with an increase in the R-wave amplitude in the inferior leads, and in five it was finally abolished by RFCA at the left sinus of Valsalva (LSV). Conversely, in four patients (33%), the second OT-VT appeared after RFCA at the LSV: two required additional RFCA applications at the LVOT to abolish the second OT-VT, and one at the RVOT, and all were associated with a decrease in the R-wave amplitude in the inferior leads. This kind of dynamic QRS morphology change was often observed when RFCA was applied to either the first or second OT-VT at a right or left ventricular endocardial site, with the other site being the LSV. A detailed continuous observation of the QRS morphology, especially of the R-wave in the inferior leads, is important for identifying changes in the QRS morphology during RFCA.
Collapse
Affiliation(s)
- Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
155
|
Kalavakolanu S, Rao HB, Kumar DN, Calambur N. Successful ablition of aortic cusp tachycardia from right ventricle outflow tract using a superior approach. J Interv Card Electrophysiol 2006; 16:187-9. [PMID: 17165134 DOI: 10.1007/s10840-006-9038-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Accepted: 07/25/2006] [Indexed: 10/23/2022]
Abstract
We report a case of successful radiofrequency catheter ablation of idiopathic aortic cusp tachycardia arising close to right coronary artery ostium performed safely from the right ventricular outflow tract (RVOT) by unconventional superior approach. As both activation mapping and pace mapping of the tachycardia were suboptimal from transfemoral RV endocardial approach, retrograde aortic mapping was performed. This revealed that the site of ventricular tachycardia (VT) origin to be on the right coronary sinus. Due to close proximity of VT site of origin and the right coronary ostium, an alternate approach to ablation was considered. We approached this area easily and successfully ablated the VT with an ablation catheter introduced from a right-sided superior approach (jugular vein). The patient has remained free from recurrences over an 18 month follow-up period.
Collapse
|
156
|
Dametto E, Proclemer A, Zardo F, Nicolosi GL. Double-exit transaortic sinus cusp ventricular tachycardia: An unusual form of idiopathic outflow tract tachycardia treated by radiofrequency catheter ablation. Heart Rhythm 2006; 3:1490-3. [DOI: 10.1016/j.hrthm.2006.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 08/22/2006] [Indexed: 11/15/2022]
|
157
|
Huang H, Wang X, Ouyang F, Antz M. Catheter ablation of anteroseptal accessory pathway in the non-coronary aortic sinus. ACTA ACUST UNITED AC 2006; 8:1041-4. [PMID: 17098777 DOI: 10.1093/europace/eul122] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report a patient with atrioventricular reentrant tachycardia (AVRT) with bidirectional conduction over an anteroseptal accessory pathway (AP) who underwent successful ablation in the non-coronary aortic sinus (AS). In three previous attempts, the intracardiac recordings showed an anteroseptal AP with antegrade and retrograde conduction that failed to be ablated in spite of radiofrequency (RF) applications from the right and left anteroseptal regions. During the study, the earliest atrial activation during tachycardia was recorded in the non-coronary AS preceding the atrial activation at the His bundle (HB) region by 24 ms, and the anteroseptal AP was successfully blocked by one single ablation in the non-coronary AS. These data strongly suggest that careful mapping of an anteroseptal AP in the non-coronary AS may provide an alternative ablation approach in patients with previously failed ablation.
Collapse
Affiliation(s)
- He Huang
- Medizinische Abteilung, Asklepios Klinik St. Georg, Lohmühlenstrasse 5, 20099 Hamburg, Germany
| | | | | | | |
Collapse
|
158
|
Obel OA, d'Avila A, Neuzil P, Saad EB, Ruskin JN, Reddy VY. Ablation of Left Ventricular Epicardial Outflow Tract Tachycardia From the Distal Great Cardiac Vein. J Am Coll Cardiol 2006; 48:1813-7. [PMID: 17084255 DOI: 10.1016/j.jacc.2006.06.006] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2005] [Revised: 07/12/2006] [Accepted: 07/18/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the feasibility and safety of ablation of idiopathic outflow tract ventricular tachycardia (OTVT) from the distal ramifications of the coronary sinus (CS). BACKGROUND A significant minority of patients presenting with idiopathic OTVT have an epicardial focus, the standard approach to which involves ablation from within one of the aortic valve cusps (AVCs). We describe the successful ablation of idiopathic epicardial OTVT from within the CS in the distal great cardiac vein (GCV). METHODS Ablation from the distal GCV was performed in 5 patients with idiopathic OTVT who had unfavorable mapping, in some cases unsuccessful ablation from various endocardial and epicardial sites including the AVCs, and in 1 patient via the direct epicardial approach. An electroanatomic mapping system (Carto) was used in 3 patients, and conventional mapping was performed in 2 patients, and in 3 patients cryothermal ablation was performed. RESULTS In all patients, the first ablation lesion in the GCV successfully eliminated the arrhythmia. All patients have remained free of VT after a mean follow-up of 24 (7 to 44) months. There were no immediate or long-term complications. CONCLUSIONS Idiopathic epicardial OTVT can be successfully ablated from the distal GCV, and should be seen as an alternative to ablation from the aortic valve cusps.
Collapse
Affiliation(s)
- Owen A Obel
- Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
| | | | | | | | | | | |
Collapse
|
159
|
d'Avila A, Thiagalingam A, Holmvang G, Houghtaling C, Ruskin JN, Reddy VY. What is the most appropriate energy source for aortic cusp ablation? A comparison of standard RF, cooled-tip RF and cryothermal ablation. J Interv Card Electrophysiol 2006; 16:31-8. [PMID: 17029021 DOI: 10.1007/s10840-006-9006-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Accepted: 04/18/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Certain tachycardias can be eliminated by catheter ablation from within the base of the aortic valve (AV) cusps but the high blood flow and proximity to the coronary arteries create unique challenges. Standard radiofrequency (RF) energy, cooled-tip RF energy or cryothermal energy were compared to determine the optimal ablation modality. MATERIALS AND METHODS Experiments were conducted using adult swine or goats (15 animals). Ablation lesions were placed using either: temperature-controlled RF (4 mm-tip catheter; 60 degrees C/60 s), cooled-tip RF (4 mm-tip catheter with internal saline circulation at 0.6 ml/s; 40 degrees C/60 s), or cryoablation (6 mm-tip spot cryocatheter; <-75 degrees C/4 min). Animals were sacrificed 1 h after the last application and lesions were subject to pathological analysis. RESULTS Standard RF and cryoablation created similar depth lesions in the right coronary cusp (4.2+/-1.3 and 3.4+/-0.5 mm, respectively) but cryoablation was unable to create any visible lesions in the non-coronary cusp. Cooled tip ablation created larger ablation lesions in the right coronary cusp (5.25+/-0.5) and fully transmural left atrial ablation lesions after ablation in the noncoronary cusp. Acute damage to the cusps was not noted with any ablation modality. Disruption of elastic fibers in the aortic media was seen after standard and cooled tip radiofrequency ablation but not cryoablation. CONCLUSION Cryoablation within the AV cusps created similar sized lesions to standard RF ablation without evidence of elastic fibre disruption and may therefore be an appropriate first line ablation modality. Cooled-tip ablation created larger ablation lesions and therefore may be required if cryoablation is ineffective.
Collapse
Affiliation(s)
- Andre d'Avila
- Cardiac Arrhythmia Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit Street/GRB 109, Boston, MA 02114, USA
| | | | | | | | | | | |
Collapse
|
160
|
Bunch TJ, Day JD. Right Meets Left: A Common Mechanism Underlying Right and Left Ventricular Outflow Tract Tachycardias. J Cardiovasc Electrophysiol 2006; 17:1059-61. [PMID: 16989647 DOI: 10.1111/j.1540-8167.2006.00577.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
161
|
Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 867] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
162
|
Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e385-484. [PMID: 16935995 DOI: 10.1161/circulationaha.106.178233] [Citation(s) in RCA: 807] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
163
|
Burkhardt JD, Saliba WI, Schweikert RA, Cummings J, Natale A. Remote magnetic navigation to map and ablate left coronary cusp ventricular tachycardia. J Cardiovasc Electrophysiol 2006; 17:1142-4. [PMID: 16879625 DOI: 10.1111/j.1540-8167.2006.00559.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Premature ventricular contractions (PVCs) and ventricular tachycardia may arise from the coronary cusps. Navigation, mapping, and ablation in the coronary cusps can be challenging. Remote magnetic navigation may offer an alternative to conventional manually operated catheters. OBJECTIVE We report a case of left coronary cusp ventricular tachycardia ablation using remote magnetic navigation. METHODS Right ventricular outflow tract and coronary cusp mapping, and ablation of the left coronary cusp using a remote magnetic navigation and three-dimensional (3-D) mapping system was performed in a 28-year-old male with frequent, symptomatic PVCs and ventricular tachycardia. RESULTS Successful ablation of left coronary cusp ventricular tachycardia was performed using remote magnetic navigation. CONCLUSIONS Remote magnetic navigation may be used to map and ablate PVCs and ventricular tachycardia originating from the coronary cusps.
Collapse
Affiliation(s)
- J David Burkhardt
- Department of Cardiovascular Medicine, Section of Cardiac Electrophysiology and Pacing, The Cleveland Clinic, Ohio 44195, USA.
| | | | | | | | | |
Collapse
|
164
|
Ouyang F, Ma J, Ho SY, Bänsch D, Schmidt B, Ernst S, Kuck KH, Liu S, Huang H, Chen M, Chun J, Xia Y, Satomi K, Chu H, Zhang S, Antz M. Focal Atrial Tachycardia Originating From the Non-Coronary Aortic Sinus. J Am Coll Cardiol 2006; 48:122-31. [PMID: 16814658 DOI: 10.1016/j.jacc.2006.02.053] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Revised: 02/07/2006] [Accepted: 02/14/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We sought to investigate electrophysiological characteristics and catheter ablation in patients with focal atrial tachycardia (AT) originating from the non-coronary aortic sinus (AS). BACKGROUND In patients with failed ablation of focal AT near the His bundle (HB) region, an origin from the non-coronary AS should be considered because of the close anatomical relationship. METHODS This study included 9 patients with focal AT, in 6 of whom attempted radiofrequency (RF) ablation had previously failed. Activation mapping was performed during tachycardia to identify an earliest activation in the atria and the AS. The aortic root angiography was performed to identify the origin in the AS before RF ablation. RESULTS Focal AT was reproducibly induced by atrial pacing. Mapping in atria demonstrated that the earliest atrial activation was located at the HB region, whereas mapping in the non-coronary AS demonstrated that an earliest atrial activation preceded the atrial activation at the HB by 12.2 +/- 6.9 ms and was anatomically located superoposterior to the HB in all 9 patients. Also, His potentials were not found at the successful site in the non-coronary AS in all 9 patients. The focal AT was terminated in <8 s in all 9 patients. Junctional beats and PR prolongation did not occur during RF application in all 9 patients. No complications occurred in any of the nine patients. All 9 patients were free of arrhythmias without antiarrhythmic drugs during a follow-up of 9 +/- 3 months. CONCLUSIONS In patients with focal AT near the HB region, mapping in the non-coronary AS can improve clinical outcome.
Collapse
Affiliation(s)
- Feifan Ouyang
- II. Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
165
|
Vaseghi M, Cesario DA, Mahajan A, Wiener I, Boyle NG, Fishbein MC, Horowitz BN, Shivkumar K. Catheter Ablation of Right Ventricular Outflow Tract Tachycardia: Value of Defining Coronary Anatomy. J Cardiovasc Electrophysiol 2006; 17:632-7. [PMID: 16836713 DOI: 10.1111/j.1540-8167.2006.00483.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Thermal damage to coronary arteries during catheter ablation has been previously reported. Coronary artery damage during LV outflow tract ventricular tachycardia is well recognized. However, the relationship of the coronary arteries to the RV outflow tract during catheter ablation has not been delineated. The purpose of this study was to define the relationship between the RV outflow tract and the coronary arteries utilizing arteriography, echocardiography, CT angiography, and gross anatomic pathology. METHODS The relationship of the coronaries to the RV outflow tract was analyzed in three patients groups: Group 1: patients (n = 10) undergoing RV outflow tract ventricular tachycardia; Group 2: patients (n = 50) undergoing CT coronary angiography; Group 3: patients (n = 4) undergoing echocardiography during open heart surgery and intracardiac echocardiography (ICE) during catheter ablation of atrial fibrillation (n = 5). RESULTS Group 1: The left main coronary artery was found to be 3.8 +/- 1.2 mm from the right ventricular outflow tract in patients undergoing ablation. Group 2: The minimum distance between the left main, left anterior descending, and right coronary artery to the RV outflow tract endocardial wall were 4.1 +/- 1.9 mm, 2.0 +/- 0.6 mm, and 4.3 +/- 1.9 mm (average +/- SD) respectively. Group 3: During open heart surgery using echocardiography, the minimum distance between the left main and the right coronary artery to the RV outflow tract were 3.4 +/- 0.35 mm and 2.0 +/- 0.1 mm, respectively. The distance between the let main coronary artery and the RVOT by ICE was 3.8 +/- 0.45 mm. CONCLUSIONS The major coronary arteries lie in close proximity of the RVOT, and their anatomic course should be taken into consideration during ablation of ventricular tachycardias arising from the RV outflow tract.
Collapse
Affiliation(s)
- Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1679, USA
| | | | | | | | | | | | | | | |
Collapse
|
166
|
Daniels DV, Lu YY, Morton JB, Santucci PA, Akar JG, Green A, Wilber DJ. Idiopathic Epicardial Left Ventricular Tachycardia Originating Remote From the Sinus of Valsalva. Circulation 2006; 113:1659-66. [PMID: 16567566 DOI: 10.1161/circulationaha.105.611640] [Citation(s) in RCA: 262] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Despite the success of catheter ablation for treatment of idiopathic ventricular tachycardia (VT), occasional patients have been reported in whom VT could not be ablated from the right or left ventricular endocardium or from the aortic sinus of Valsalva (ASOV).
Methods and Results—
In 12 of 138 patients (9%) with idiopathic VT referred for ablation, an epicardial left ventricular site of origin was identified >10 mm from the ASOV. Coronary venous mapping demonstrated epicardial preceding endocardial activation by >10 ms (41±7 versus 15±11 ms before QRS onset;
P
<0.001). VT induction was facilitated by catecholamines and terminated by adenosine. Ablation through the coronary veins or via percutaneous transpericardial catheterization was successful in 9 patients; 2 required direct surgical ablation as a result of anatomic constraints. No ECG pattern was specific for epicardial VT. However, slowed initial precordial QRS activation, as quantified by a novel metric, the maximum deflection index, was more useful. A delayed precordial maximum deflection index ≥0.55 identified epicardial VT remote from the ASOV with a sensitivity of 100% and a specificity of 98.7% relative to all other sites of origin (
P
<0.001).
Conclusions—
Although clinically underrecognized, idiopathic VT may originate from the perivascular sites on the left ventricular epicardium. The mechanism is consistent with triggered activity. It is amenable to ablation by transvenous or transpericardial approaches, although technical challenges remain. Recognition of a prolonged precordial maximum deflection index and early use of transvenous epicardial mapping are critical to avoid protracted and unsuccessful ablation elsewhere in the ventricles.
Collapse
Affiliation(s)
- David V Daniels
- Cardiovascular Institute, Loyola University Medical Center, Maywood, IL 60153, USA
| | | | | | | | | | | | | |
Collapse
|
167
|
Meininger GR, Berger RD. Idiopathic ventricular tachycardia originating in the great cardiac vein. Heart Rhythm 2006; 3:464-6. [PMID: 16567296 DOI: 10.1016/j.hrthm.2005.12.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2005] [Accepted: 12/23/2005] [Indexed: 11/21/2022]
Affiliation(s)
- Glenn R Meininger
- Department of Medicine, Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | | |
Collapse
|
168
|
Hirasawa Y, Miyauchi Y, Iwasaki YK, Kobayashi Y. Successful Radiofrequency Catheter Ablation of Epicardial Left Ventricular Outflow Tract Tachycardia from the Anterior Interventricular Coronary Vein. J Cardiovasc Electrophysiol 2005; 16:1378-80. [PMID: 16403074 DOI: 10.1111/j.1540-8167.2005.00257.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We report a case of idiopathic left ventricular outflow tract (LVOT) tachycardia that was eliminated by a radiofrequency application from the anterior interventricular coronary vein (AIV). The ECG exhibited QRS complexes with an inferior axis and atypical left bundle branch block pattern with an early transition of the precordial R waves at V3. Several radiofrequency applications from the coronary cusps and endocardial LVOT were not effective. Radiofrequency applications in the AIV, where the activation preceded the onset of the QRS by 30 msec, successfully eliminated the tachycardia. The AIV may be an optional site for radiofrequency ablation of idiopathic epicardial LVOT tachycardia.
Collapse
Affiliation(s)
- Yasuhiro Hirasawa
- First Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | | | | | | |
Collapse
|
169
|
Atienza F, Arenal A, Ormaetxe J, Almendral J. Epicardial Idiopathic Ventricular Tachycardia Originating Within the Left Main Coronary Artery Ostium Area: Identification Using the LocaLisa Nonfluoroscopic Catheter Navigation System. J Cardiovasc Electrophysiol 2005; 16:1239-42. [PMID: 16302910 DOI: 10.1111/j.1540-8167.2005.40773.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Idiopathic ventricular tachycardia (IVT) in patients without structural heart disease commonly arises from the right or left outflow tracts, but there remain arrhythmias that can only be ablated by an epicardial approach. We report a case of an epicardial ventricular tachycardia originating within the left main coronary artery ostium area, as identified using the LocaLisa nonfluoroscopic catheter navigation system. Due to the high risk of coronary artery thrombosis, ventricular tachycardia was successfully ablated by a transthoracic surgical approach using cryoenergy. Ventricular ectopy disappeared and ventricular tachycardia did not recur during long-term follow-up.
Collapse
Affiliation(s)
- Felipe Atienza
- Electrophysiology Laboratory, Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | | |
Collapse
|
170
|
Tada H, Kurosaki K, Ito S, Naito S, Yamada M, Miyaji K, Hashimoto T, Oshima S, Nogami A, Taniguchi K. Idiopathic premature ventricular contractions arising from the pulmonary artery: importance of mapping in the pulmonary artery in left bundle branch block-shaped ventricular arrhythmias. Circ J 2005; 69:865-9. [PMID: 15988115 DOI: 10.1253/circj.69.865] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A patient underwent radiofrequency (RF) catheter ablation of symptomatic idiopathic ventricular contractions (PVCs). RF energy applications at 2 sites in the right ventricular outflow tract (RVOT), where both the earliest ventricular activation and near-perfect pace mapping were obtained, did not abolish the PVC but resulted in changes in the QRS morphology of the PVC. Complete elimination of the PVC was achieved with RF energy application at a site within the pulmonary artery 13 mm above the pulmonary valve, which was greater than 20 mm away from the failed ablation sites within the RVOT.
Collapse
Affiliation(s)
- Hiroshi Tada
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
171
|
Yamauchi Y, Aonuma K, Takahashi A, Sekiguchi Y, Hachiya H, Yokoyama Y, Kumagai K, Nogami A, Iesaka Y, Isobe M. Electrocardiographic Characteristics of Repetitive Monomorphic Right Ventricular Tachycardia Originating Near the His-Bundle. J Cardiovasc Electrophysiol 2005; 16:1041-8. [PMID: 16191113 DOI: 10.1111/j.1540-8167.2005.40787.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Most idiopathic nonreentrant ventricular tachycardia (VT) and ventricular premature contractions (VPCs) arise from the right or left ventricular outflow tract (OT). However, some right ventricular (RV) VT/VPCs originate near the His-bundle region. The aim of this study was to investigate ECG characteristics of VT/VPCs originating near the His-bundle in comparison with right ventricular outflow tract (RVOT)-VT/VPCs. METHODS AND RESULTS Ninety RV-VT/VPC patients underwent catheter mapping and radiofrequency ablation. ECG variables were compared between VT/VPCs originating from the RVOT and near the His-bundle. Ten patients had foci near the His-bundle (HIS group), with the His-bundle local ventricular electrogram preceding the QRS onset by 15-35 msec (mean: 22 msec) and His-bundle pacing produced a nearly identical ECG to clinical VT/VPCs. The HIS group R wave amplitude in the inferior leads (lead III: 1.0 +/- 0.6 mV) was significantly lower than that of the RVOT group (1.7 +/- 0.4 mV, P < 0.05). An R wave in aVL was present in 6 of 10 HIS group patients, while almost all RVOT group patients had a QS pattern in aVL. Lead I in HIS group exhibited significantly taller R wave amplitudes than RVOT group. HIS group QRS duration in the inferior leads was shorter than that of the RVOT group. Eight of 10 HIS group patients exhibited a QS pattern in lead V1 compared to 14 of 81 RVOT group patients. HIS group had larger R wave amplitudes in leads V5 and V6 than RVOT group. CONCLUSION VT/VPCs originating near the His-bundle have distinctive ECG characteristics. Knowledge of the characteristic QRS morphology may facilitate catheter mapping and successful ablation.
Collapse
|
172
|
HIRASAWA YASUHIRO, MIYAUCHI YASUSHI, IWASAKI YUKI, KOBAYASHI YOSHINORI. Successful Radiofrequency Catheter Ablation of Epicardial Left Ventricular Outflow Tract Tachycardia from the Anterior Interventricular Coronary Vein. J Cardiovasc Electrophysiol 2005. [DOI: 10.1111/j.1540-8167.2005.50164.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
173
|
Moorman AFM, Christoffels VM, Anderson RH. Anatomic substrates for cardiac conduction. Heart Rhythm 2005; 2:875-86. [PMID: 16051128 DOI: 10.1016/j.hrthm.2005.04.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2005] [Accepted: 04/18/2005] [Indexed: 11/30/2022]
Affiliation(s)
- Antoon F M Moorman
- Department of Anatomy and Embryology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | | |
Collapse
|
174
|
Dixit S, Gerstenfeld EP, Lin D, Callans DJ, Hsia HH, Nayak HM, Zado E, Marchlinski FE. Identification of distinct electrocardiographic patterns from the basal left ventricle: Distinguishing medial and lateral sites of origin in patients with idiopathic ventricular tachycardia. Heart Rhythm 2005; 2:485-91. [PMID: 15840472 DOI: 10.1016/j.hrthm.2005.01.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2005] [Accepted: 01/18/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Idiopathic ventricular tachycardias (IVTs) can originate from the basal left ventricle (LV). OBJECTIVE To determine if using magnetic electroanatomic mapping (MEAM) for accurate localization (1) unique ECG morphologies on pace maps from medial and lateral sites in basal LV could be identified and (2) this ECG information would facilitate VT localization. METHODS In 12 patients with structurally normal hearts undergoing ablation for IVT, detailed MEAM of LV was constructed in sinus rhythm and pace-mapping was done from the septal-parahisian (S-P) region, aortomitral continuity (AMC), and superior, superolateral, and lateral mitral annular (MA) locations. Pace maps were analyzed for ECG morphologies in limb leads and transition patterns in precordial leads. RESULTS Medial pacing sites (S-P and AMC) compared with lateral sites (superolateral and lateral MA) demonstrated narrower QRS complexes (134 +/- 24 msec vs. 182 +/- 18 msec; P < .05) with initial negative forces in lead V1 and predominantly positive forces in lead I (amplitude 0.59 +/- 0.27 mV vs. 0.16 +/- 0.34 mV; P < .05). The ratio of QRS complexes in leads II and III was >1 for all (12 of 12) S-P pace maps and 11 of 12 lateral MA pace maps but remained < or =1 for pace maps from 10 of 12 AMC locations, 11 of 12 superior MA locations, and 10 of 11 superolateral MA locations. Using these ECG criteria, a blinded reviewer was able to accurately localize the site of origin (SOO) of clinical arrhythmia (successful ablation site on MEAM) in 10 of 12 cases (83%) of IVT originating from basal LV. CONCLUSION Pace maps from basal LV endocardium manifest site-dependent ECG morphologies that can help differentiate medial from lateral locations and can predict the SOO of clinical arrhythmias from this region.
Collapse
Affiliation(s)
- Sanjay Dixit
- Cardiac Electrophysiology Section, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.
| | | | | | | | | | | | | | | |
Collapse
|
175
|
Josephson ME, Callans DJ. Using the twelve-lead electrocardiogram to localize the site of origin of ventricular tachycardia. Heart Rhythm 2005; 2:443-6. [PMID: 15851350 DOI: 10.1016/j.hrthm.2004.12.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Mark E Josephson
- Division of Cardiovascular Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
| | | |
Collapse
|
176
|
Tada H, Toide H, Naito S, Ito S, Kurosaki K, Kobayashi Y, Miyaji K, Yamada M, Oshima S, Nogami A, Taniguchi K. Tissue tracking imaging as a new modality for identifying the origin of idiopathic ventricular arrhythmias. Am J Cardiol 2005; 95:660-4. [PMID: 15721115 DOI: 10.1016/j.amjcard.2004.10.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2004] [Revised: 10/22/2004] [Accepted: 10/22/2004] [Indexed: 11/26/2022]
Abstract
Tissue tracking imaging was performed in 33 patients with idiopathic ventricular arrhythmias before radiofrequency catheter ablation. The site of the arrhythmia origin, defined as the site where the earliest color-coded signal appeared on the myocardium at the onset of the arrhythmia, corresponded to the site of origin as determined on fluoroscopy during activation mapping in all patients. Catheter ablation at that site abolished the arrhythmia in 29 patients (88%).
Collapse
Affiliation(s)
- Hiroshi Tada
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
177
|
Sekiguchi Y, Aonuma K, Takahashi A, Yamauchi Y, Hachiya H, Yokoyama Y, Iesaka Y, Isobe M. Electrocardiographic and electrophysiologic characteristics of ventricular tachycardia originating within the pulmonary artery. J Am Coll Cardiol 2005; 45:887-95. [PMID: 15766825 DOI: 10.1016/j.jacc.2004.10.071] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2004] [Accepted: 10/27/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We investigated the electrocardiographic (ECG) and electrophysiologic characteristics of ventricular tachycardia (VT) originating within the pulmonary artery (PA). BACKGROUND Radiofrequency catheter ablation (RFCA) is routinely applied to the endocardial surface of the right ventricular outflow tract (RVOT) in patients with idiopathic VT of left bundle branch block morphology. It was recently reported that this arrhythmia may originate within the PA. METHODS Activation mapping and ECG analysis were performed in 24 patients whose VTs or ventricular premature contractions (VPCs) were successfully ablated within the PA (PA group) and in 48 patients whose VTs or VPCs were successfully ablated from the endocardial surface of the RVOT (RV-end-OT group). RESULTS R-wave amplitudes on inferior ECG leads, aVL/aVR ratio of Q-wave amplitude, and R/S ratio on lead V(2) were significantly larger in the PA group than in the RV-end-OT group. On intracardiac electrograms, atrial potentials were more frequently recorded in the PA group than in the RV-end-OT group (58% vs. 12%; p < 0.01). The amplitude of local ventricular potentials recorded during sinus rhythm within the PA was significantly lower than that recorded from the RV-end-OT (0.62 +/- 0.56 mV vs. 1.55 +/- 0.88 mV; p < 0.01). CONCLUSIONS Ventricular tachycardia originating within the PA has different electrocardiographic and electrophysiologic characteristics from that originating from the RV-end-OT. When mapping the RVOT area, the catheter may be located within the PA if a low-voltage atrial or local ventricular potential of <1-mV amplitude is recorded. Heightened attention must be paid if RFCA is required within the PA.
Collapse
Affiliation(s)
- Yukio Sekiguchi
- Cardiovascular Center, Yokosuka Kyosai General Hospital, Kanagawa, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
178
|
Tada H, Ito S, Naito S, Kurosaki K, Kubota S, Sugiyasu A, Tsuchiya T, Miyaji K, Yamada M, Kutsumi Y, Oshima S, Nogami A, Taniguchi K. Idiopathic ventricular arrhythmia arising from the mitral annulus. J Am Coll Cardiol 2005; 45:877-86. [PMID: 15766824 DOI: 10.1016/j.jacc.2004.12.025] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2004] [Revised: 10/20/2004] [Accepted: 12/06/2004] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We sought to clarify the prevalence and characteristics of idiopathic ventricular tachycardia or premature ventricular contraction originating from the mitral annulus (MAVT/PVC). BACKGROUND Recent case reports have presented patients with MAVT/PVC. METHODS Electrocardiographic (ECG) characteristics and the results of electrophysiologic investigation and radiofrequency catheter ablation (RFCA) were analyzed in 352 patients with symptomatic idiopathic ventricular tachycardia (IVT)/premature ventricular contraction (PVC). RESULTS Nineteen cases of IVT/PVC (5%) represented MAVT/PVC. Of these, 11 (58%) originated from the anterolateral portion of the mitral annulus (AL-MAVT/PVC), and 2 (11%) arose from the posterior portion (Pos-MAVT/PVC). The remaining six cases of MAVT/PVC (31%) had posteroseptal origin (PS-MAVT/PVC). In all patients, an S-wave was present in lead V(6). The QRS polarity in inferior leads and leads I and aVL was useful for differentiating AL-MAVT/PVC from Pos-MAVT/PVC or PS-MAVT/PVC. The Pos-MAVT/PVC had an Rs pattern in lead I and an R pattern in lead V(1), whereas PS-MAVT/PVC invariably had an R pattern in lead I and a negative QRS component in lead V(1). The AL-MAVT/PVC and Pos-MAVT/PVC showed a longer QRS duration than the PS-MAVT/PVC (p < 0.001), and all had late-phase "notching" of the QRS complex in inferior leads. In all patients, RFCA eliminated MAVT/PVC, with no recurrences during follow-up for 21 +/- 15 months. CONCLUSIONS Mitral annular VT/PVC is a rare but distinct subgroup of IVT/PVC. MAVT/PVC origin could be determined by ECG analysis. The AL and PS sites of the MA were preferential.
Collapse
Affiliation(s)
- Hiroshi Tada
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
179
|
Tanner H, Hindricks G, Schirdewahn P, Kobza R, Dorszewski A, Piorkowski C, Gerds-Li JH, Kottkamp H. Outflow tract tachycardia with R/S transition in lead V3. J Am Coll Cardiol 2005; 45:418-23. [PMID: 15680722 DOI: 10.1016/j.jacc.2004.10.037] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2004] [Revised: 10/02/2004] [Accepted: 10/04/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study was to analyze different anatomic mapping approaches for successful ablation of outflow tract tachycardia with R/S transition in lead V(3). BACKGROUND Idiopathic ventricular tachycardia can originate from different areas in the outflow tract, including the right and left ventricular endocardium, the epicardium, the pulmonary artery, and the aortic sinus of Valsalva. Although electrocardiographic criteria may be helpful in predicting the area of origin, sometimes the focus is complex to determine, especially when QRS transition in precordial leads is in V(3). METHODS We analyzed surface electrocardiograms of 33 successfully ablated patients with outflow tract tachycardia: 20 from the right ventricular outflow tract (RVOT) and 13 from different sites. The R/S transition was determined, and the different anatomic approaches needed for successful catheter ablation were studied. RESULTS Overall, R/S transition in lead V(3) was present in 19 (58%) of all patients. In these patients, mapping was started and successfully completed in the RVOT in 11 of 19 (58%) patients. The remaining eight patients with R/S transition in lead V(3) needed five additional anatomic accesses for successful ablation: from the left ventricular outflow tract (n = 3), aortic sinus of Valsalva (n = 2), coronary sinus (n = 1), the epicardium via pericardial puncture (n = 1), and the trunk of the pulmonary artery (n = 1), respectively. CONCLUSIONS A R/S transition in lead V(3) is common. In patients with outflow tract tachycardia with R/S transition in lead V(3), a stepwise endocardial and epicardial mapping through up to six anatomic approaches can lead to successful radiofrequency catheter ablation.
Collapse
Affiliation(s)
- Hildegard Tanner
- University of Leipzig-Heart Center, Cardiology, Department of Electrophysiology, Struempellstrasse 39, D-04289 Leipzig, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
180
|
Ito S, Tada H, Naito S, Kurosaki K, Ueda M, Shinbo G, Oshima S, Nogami A, Taniguchi K. Simultaneous Mapping in the Left Sinus of Valsalva and Coronary Venous System Predicts Successful Catheter Ablation from the Left Sinus of Valsalva. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28 Suppl 1:S150-4. [PMID: 15683485 DOI: 10.1111/j.1540-8159.2005.00081.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Idiopathic ventricular tachycardia originating from the left epicardium (Epi-VT) can be ablated from the left sinus of Valsalva (LSV) in selected patients. We hypothesized that the analysis of electrograms at the LSV and transitional zone from the great cardiac vein to the anterior interventricular vein (GCV-AIV) could predict the efficacy of radiofrequency catheter ablation (RFCA) from the LSV. Simultaneous mapping in the LSV and coronary venous system was performed in 25 patients (12 VTs and 13 premature ventricular contractions). The earliest ventricular activation (VA) during the arrhythmias was found at the LSV or GCV-AIV in all patients. RF applications from the LSV were successful in 17 patients success group (S-Gr) and failed in 8 failure group (F-Gr). The earliness of the VA recorded in the LSV (VA[LSV]) and in GCV-AIV (VA[GCV-AIV]) was compared between the two groups. (1) The VA[LSV] preceded the QRS onset by 28 +/- 11 ms in S-Gr and 14 +/- 10 ms in F-Gr (P < 0.01). (2) In S-Gr, the VA[GCV-AIV] was earlier than the VA[LSV] in 5 five patients (35%). However, in F-Gr, the VA[GCV-AIV] was earlier than the VA[LSV] in all patients. (3) In patients in whom the earliest VA was found at the LSV or GCV-AIV, a VA [GCV-AIV] preceding the VA[LSV] by less than 10 ms identified successful RFCA from the LSV with a sensitivity of 88 %, specificity of 100%, and high predictive value. With a detailed analysis of the electrograms recorded from the GCV-AIV and LSV, it was possible to identify the successful catheter ablation of Epi-VT from the LSV.
Collapse
Affiliation(s)
- Sachiko Ito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
181
|
Tsuchiya T, Yamamoto K, Tanaka E, Tashiro H. Reentrant Ventricular Tachycardia Originating from the Aortic Sinus Cusp:. J Cardiovasc Electrophysiol 2004; 15:1216-9. [PMID: 15485451 DOI: 10.1046/j.1540-8167.2004.03695.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a case of idiopathic reentrant ventricular tachycardia (VT) originating from the left aortic sinus cusp. A prepotential preceding the QRS complex by 58 ms was recorded from the posterior right ventricular (RV) outflow tract. During VT entrainment observed by pacing from the midseptal RV, it initially was orthodromically captured with a long conduction time but then antidromically captured as the pacing cycle rate was increased. Pacing at that site failed to show concealed entrainment despite a postpacing interval similar to the VT cycle length. Radiofrequency catheter ablation abolished the VT in the left aortic sinus cusp where a prepotential preceding the QRS complex by 78 ms with a postpacing interval similar to the VT cycle length was recorded in addition to concealed entrainment. The findings suggest that, in this VT, a critical slow conduction zone is partially present extending from the left aortic sinus cusp to the posterior right ventricular outflow tract. The patient has remained free from VT recurrence after 5-month follow-up.
Collapse
|
182
|
Tada H, Hiratsuji T, Naito S, Kurosaki K, Ueda M, Ito S, Shinbo G, Hoshizaki H, Oshima S, Nogami A, Taniguchi K. Prevalence and Characteristics of Idiopathic Outflow Tract Tachycardia with QRS Alteration Following Catheter Ablation Requiring Additional Radiofrequency Ablation at a Different Point in the Outflow Tract. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:1240-9. [PMID: 15461714 DOI: 10.1111/j.1540-8159.2004.00615.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Subtle variations in QRS morphology occurs during idiopathic outflow tract ventricular tachycardia (OTVT), but no studies have clarified the prevalence and characteristics of the OTVT with altered QRS morphology following radiofrequency catheter ablation (RFA), which then require an additional RF application at a different portion of the outflow tract to abolish OTVT. Of 202 patients with a monomorphic VT or premature ventricular contraction (PVC) originating from the outflow tract, 6 (3%) showed changes in QRS morphology in the OTVT following RFA, requiring an additional RF application to the outflow tract at a different portion. In all six patients, RFA was applied for the first or second OTVT to a right or left ventricular endocardial site, with the other site being the left sinus of Valsalva. In each patient, OTVT before or after the changes in QRS morphology had characteristic ECG findings originating from a particular portion of the outflow tract. Changes in QRS morphology consistently included an increase or decrease in R wave amplitude in all inferior leads. Detailed continuous observation of QRS morphology in OTVT, especially R wave amplitude in inferior leads, is important for identifying changes of QRS morphology during catheter ablation. Mapping and ablation at a different portion of the outflow tract is then needed for cure.
Collapse
Affiliation(s)
- Hiroshi Tada
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
183
|
Morwood JG, Triedman JK, Berul CI, Khairy P, Alexander ME, Cecchin F, Walsh EP. Radiofrequency catheter ablation of ventricular tachycardia in children and young adults with congenital heart disease. Heart Rhythm 2004; 1:301-8. [PMID: 15851174 DOI: 10.1016/j.hrthm.2004.05.009] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2004] [Accepted: 05/10/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The aim of this study was to expand data on outcomes for radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) in young patients and to identify obstacles to success. BACKGROUND Ablation of VT is performed infrequently in young patients. Published experience has been limited to case reports and small descriptive series. METHODS A retrospective review of 97 consecutive VT ablation procedures involving 62 patients at a single institution from 1990 to 2003 was undertaken. All intention-to-treat procedures were analyzed. RESULTS Mean age was 13.9 +/- 9.4 years. Procedures were categorized according to VT mechanism as follows: idiopathic right ventricle (n = 37); idiopathic left ventricle (n = 24); congenital heart disease (n = 20); or other structural disease (n = 16). Acute success was achieved in 58 (60%) of 97 procedures. Of the 39 failures, 33 were aborted cases due to inability to induce sufficient ectopy for mapping in 12, high-risk location near the His bundle or coronary artery in 11, unstable VT in 7, and anatomic obstacles in 3. Recurrence rate after acutely successful RFCA was 34% (20/58 procedures) at a mean follow-up of 3.8 +/- 2.0 years. Ultimately, long-term success was achieved in 38 (61%) of 62 patients after a mean of 1.6 +/- 0.9 procedures, with the highest success rate (87%) for idiopathic left ventricular tachycardia. CONCLUSIONS When analyzed on a strict intention-to-treat basis, a long-term success rate of 61% is observed with ablation of VT in young patients. Inability to induce stable VT for precision mapping and certain high-risk VT locations can be significant obstacles to success.
Collapse
Affiliation(s)
- James G Morwood
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | |
Collapse
|
184
|
Tada H, Naito S, Ito S, Kurosaki K, Ueda M, Shinbo G, Hoshizaki H, Oshima S, Taniguchi K, Nogami A. Significance of Two Potentials for Predicting Successful Catheter Ablation From the Left Sinus of Valsalva for Left Ventricular Epicardial Tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:1053-9. [PMID: 15305952 DOI: 10.1111/j.1540-8159.2004.00584.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to identify the characteristics of electrograms that may be helpful in predicting successful ablation of idiopathic ventricular tachycardia from the aortic sinus of Valsalva. Data were obtained from 23 patients with symptomatic ventricular tachycardia or premature ventricular contractions (LV-VT) who underwent RF catheter ablation from the left sinus of Valsalva. Electrograms before and after application of RF energy during sinus rhythm and during LV-VT were analyzed. Complete elimination of LV-VT was finally achieved in 21 (91%) patients. The incidence of presystolic potentials preceding the QRS complex of LV-VT (P1 potential) was 90% for the 21 successful ablation sites, which did not differ from the incidence for the 24 unsuccessful sites (79%; P = 0.5). During sinus rhythm, a potential following the QRS complex (P2 potential) was more often recorded at the successful ablation site than at an unsuccessful ablation site before and after application of RF energy (before, P < 0.05; after, P < 0.001). The appearance of the P2 potential or a delay in the preexisting P2 potential after application of RF energy was observed only at the successful ablation sites (P < 0.001). In 18 control individuals who had no LV-VT, no P2 potential was recorded within the left sinus of Valsalva. Although the P1 potential may be useful for identifying the successful ablation site, its sensitivity is low. The appearance of the P2 potential or an increasingly delayed P2 potential after application of RF energy may be more useful than the P1 potential for predicting successful ablation.
Collapse
Affiliation(s)
- Hiroshi Tada
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
185
|
Affiliation(s)
- Douglas L Packer
- Division of Cardiology/Electrophysiology, Mayo School of Medicine, Rochester, Minnesota 55902, USA.
| |
Collapse
|
186
|
Packer DL. Evolution of Mapping and Anatomic Imaging of Cardiac Arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:1026-49. [PMID: 15271032 DOI: 10.1111/j.1540-8159.2004.00581.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Douglas L Packer
- Division of Cardiology/Electrophysiology, Mayo School of Medicine, Rochester, Minnesota, USA.
| |
Collapse
|
187
|
Affiliation(s)
- Mark E Josephson
- Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| |
Collapse
|
188
|
Weiss R, Daoud EG. The electrocardiogram: another three-dimensional mapping system for ablation of outflow tract tachycardias. J Cardiovasc Electrophysiol 2003; 14:1287-8. [PMID: 14678102 DOI: 10.1046/j.1540-8167.2003.03511.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
189
|
Ito S, Tada H, Naito S, Kurosaki K, Ueda M, Hoshizaki H, Miyamori I, Oshima S, Taniguchi K, Nogami A. Development and Validation of an ECG Algorithm for Identifying the Optimal Ablation Site for Idiopathic Ventricular Outflow Tract Tachycardia. J Cardiovasc Electrophysiol 2003; 14:1280-6. [PMID: 14678101 DOI: 10.1046/j.1540-8167.2003.03211.x] [Citation(s) in RCA: 230] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Idiopathic ventricular outflow tract tachycardia or premature ventricular contractions (OT-VTs) can originate from several different sites in the outflow tract, including the left ventricular (LV) endocardium and epicardium. The aims of this study were (1) to develop an ECG algorithm to predict the origin of OT-VT and (2) to test prospectively the accuracy of the algorithm. METHODS AND RESULTS An algorithm was developed by correlating the 12-lead ECG findings with the catheter ablation site in 80 patients with OT-VT. The ECG characteristics of the QRS complex during the arrhythmia were analyzed. The catheter sites were verified by multi-plane fluoroscopy. The outflow tract was classified into six subdivisions: right ventricular (RV) septum, RV free wall, RV near the His-bundle region, LV endocardium, left sinus of Valsalva (LSV), and LV epicardium remote from the LSV. An OT-VT originating from the LV epicardium remote from the LSV was defined as an OT-VT in which the earliest ventricular activation was recorded at the LSV and radiofrequency ablation from the LSV failed. This algorithm subsequently was tested prospectively in 88 patients. Overall sensitivity was 88% and specificity was 95%. The positive and negative predictive values were 88% and 96%, respectively. CONCLUSION We describe a new ECG algorithm having a high sensitivity and specificity to identify the optimal ablation site for idiopathic ventricular outflow tachycardia or premature ventricular contractions.
Collapse
Affiliation(s)
- Sachiko Ito
- Third Department of Internal Medicine, Fukui Medical University, Matsuoka, Fukui, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
190
|
Moorman AFM, Christoffels VM. Cardiac chamber formation: development, genes, and evolution. Physiol Rev 2003; 83:1223-67. [PMID: 14506305 DOI: 10.1152/physrev.00006.2003] [Citation(s) in RCA: 455] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Concepts of cardiac development have greatly influenced the description of the formation of the four-chambered vertebrate heart. Traditionally, the embryonic tubular heart is considered to be a composite of serially arranged segments representing adult cardiac compartments. Conversion of such a serial arrangement into the parallel arrangement of the mammalian heart is difficult to understand. Logical integration of the development of the cardiac conduction system into the serial concept has remained puzzling as well. Therefore, the current description needed reconsideration, and we decided to evaluate the essentialities of cardiac design, its evolutionary and embryonic development, and the molecular pathways recruited to make the four-chambered mammalian heart. The three principal notions taken into consideration are as follows. 1) Both the ancestor chordate heart and the embryonic tubular heart of higher vertebrates consist of poorly developed and poorly coupled "pacemaker-like" cardiac muscle cells with the highest pacemaker activity at the venous pole, causing unidirectional peristaltic contraction waves. 2) From this heart tube, ventricular chambers differentiate ventrally and atrial chambers dorsally. The developing chambers display high proliferative activity and consist of structurally well-developed and well-coupled muscle cells with low pacemaker activity, which permits fast conduction of the impulse and efficacious contraction. The forming chambers remain flanked by slowly proliferating pacemaker-like myocardium that is temporally prevented from differentiating into chamber myocardium. 3) The trabecular myocardium proliferates slowly, consists of structurally poorly developed, but well-coupled, cells and contributes to the ventricular conduction system. The atrial and ventricular chambers of the formed heart are activated and interconnected by derivatives of embryonic myocardium. The topographical arrangement of the distinct cardiac muscle cells in the forming heart explains the embryonic electrocardiogram (ECG), does not require the invention of nodes, and allows a logical transition from a peristaltic tubular heart to a synchronously contracting four-chambered heart. This view on the development of cardiac design unfolds fascinating possibilities for future research.
Collapse
Affiliation(s)
- Antoon F M Moorman
- Department of Anatomy & Embryology, Academic Medical Center, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands.
| | | |
Collapse
|
191
|
Timmermans C, Rodriguez LM, Crijns HJGM, Moorman AFM, Wellens HJJ. Idiopathic Left Bundle-Branch Block–Shaped Ventricular Tachycardia May Originate Above the Pulmonary Valve. Circulation 2003; 108:1960-7. [PMID: 14530199 DOI: 10.1161/01.cir.0000095026.19339.bb] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Idiopathic left bundle-branch block (LBBB)–like ventricular tachycardia (VT) is considered to originate in the right ventricular outflow tract (RVOT) or from the aortic root. Both regions are derived from the embryonic outflow tract. We now report that also the pulmonary trunk can give rise to VT, suggesting a common etiology of these tachycardias.
Methods and Results—
We studied 6 patients with symptomatic idiopathic LBBB-VT using electrophysiological mapping techniques. The VT origin was determined by analyzing the electrograms and the angiographic location of the catheter tip at the successful ablation site or the earliest activation site. Eight VTs were induced. Two VTs, with a mean earliest endocardial activation time of −5 and −20 ms and optimal pace mapping, were successfully ablated in the RVOT. In the remaining 6 VTs, the earliest activation site was found in the pulmonary artery, and, at this site, a sharp potential was present −38±12 ms before the QRS in 5 VTs. The mean earliest endocardial activation time in the RVOT was −1±2 ms. Ablation was attempted in 5 of 6 VTs and resulted in an acutely successful procedure. After a mean follow-up of 10±4 months, 1 of 5 patients had a recurrence.
Conclusions—
The site of origin of idiopathic LBBB-VT can be in the root of the pulmonary artery, suggesting a myocardial connection from this site to the RVOT. If no good criteria for ablation in the RVOT are found, detailed mapping of the pulmonary artery should be performed.
Collapse
Affiliation(s)
- Carl Timmermans
- Department of Cardiology, Academic Hospital Maastricht, CARIM, P. Debyelaan 25, PO Box 5800, Maastricht, The Netherlands.
| | | | | | | | | |
Collapse
|
192
|
Tierney SP, Wilber DJ. Catheter Ablation of Ventricular Tachycardia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2003; 5:377-385. [PMID: 12941206 DOI: 10.1007/s11936-003-0044-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Most patients with ventricular tachycardia (VT) associated with structural heart disease should receive an implantable cardioverter-defibrillator as initial therapy. Patients with symptomatic recurrences of tachycardia, including those with multiple defibrillator shocks, are considered for ablation. The vigor with which antiarrhythmic drug therapy is pursued as antecedent therapy to ablation depends on patient factors (eg, medical comorbidity, type of heart disease, number and hemodynamic tolerance of tachycardias) and the previous history of antiarrhythmic drug exposure (eg, side effects, inefficacy). In patients with mild left ventricular dysfunction and well-tolerated tachycardia, ablation may be offered as primary definitive therapy in selected individuals. In patients without structural heart disease, ablation is usually offered as primary definitive therapy to highly symptomatic patients, and is strongly recommended for patients with recurrent tachycardia following initial attempts at drug suppression. Optimal outcome of VT ablation depends on the availability of an experienced team and sophisticated facilities to accommodate the technical challenges associated with the broad spectrum of clinical presentations and arrhythmia mechanisms. Historically, major complications have been reported in up to 10% of patients, including death, stroke, cardiac tamponade, complete heart block, and myocardial infarction. In our own experience with VT ablation over the past 10 years, major complications occurred in three (1.8%) of 168 patients with structural heart disease and one (0.7%) of 142 patients without structural heart disease.
Collapse
Affiliation(s)
- Sean P. Tierney
- Cardiovascular Institute, Loyola University Medical Center, 2160 S. 1st Avenue, Maywood, IL 60153, USA.
| | | |
Collapse
|
193
|
Josephson ME. Electrophysiology of Ventricular Tachycardia:. A Historical Perspective. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2003; 26:2052-67. [PMID: 14516353 DOI: 10.1046/j.1460-9592.2003.00320.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mark E Josephson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
| |
Collapse
|
194
|
Ouyang F, Antz M, Deger FT, Bänsch D, Schaumann A, Ernst S, Kuck KH. An underrecognized subepicardial reentrant ventricular tachycardia attributable to left ventricular aneurysm in patients with normal coronary arteriograms. Circulation 2003; 107:2702-9. [PMID: 12743007 DOI: 10.1161/01.cir.0000068343.69532.b6] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with apparently normal hearts, ventricular tachycardia (VT) may only involve the subepicardial myocardium. METHODS AND RESULTS Four patients with exercise-induced fast VT with right bundle branch block morphology were investigated. ECG showed a small q wave in leads II, III, and aVF during sinus rhythm (SR) in all 4 patients. Left ventricular angiography showed small inferolateral aneurysms in all patients. Coronary arteriograms were normal in all 4 patients. Six unstable VTs (cycle length, 200 to 305 ms) and 1 stable VT (cycle length 370 ms) were reproducibly induced in the 4 patients. During SR, endocardial mapping was normal in all 4 patients, and epicardial mapping showed fragmented and late potentials in the left inferolateral wall anatomically consistent with the left ventricle aneurysm. During tachycardia, epicardial mapping showed a macroreentrant VT with focal endocardial activation in the patient with stable VT, whereas in 2 patients with unstable VT, a diastolic potential was only recorded and coincided with the late potential in the same area. Epicardial ablation was performed in 3 patients and successfully abolished those VTs. No VT recurred in 2 patients during follow-up of 2 and 9 months. Clinical VT recurred 6 months after the ablation and was successfully ablated in a repeated epicardial ablation in 1 patient. In the remaining patient without epicardial ablation, an implantable cardiac defibrillator was implanted. There were multiple shocks during a follow-up of 31 months. CONCLUSIONS In patients with normal coronary arteriograms and left ventricle aneurysm, exercise-induced VT with right bundle branch block morphology may have a subepicardial arrhythmogenic substrate, which may be amenable to epicardial ablation.
Collapse
Affiliation(s)
- Feifan Ouyang
- II. Med. Abteilung, Allgemeines Krankenhaus St Georg, Lohmühlenstr. 5, 20099 Hamburg, Germany.
| | | | | | | | | | | | | |
Collapse
|
195
|
Reddy VY, Neuzil P, Ruskin JN. Extra-ostial pulmonary venous isolation: use of epicardial ablation to eliminate a point of conduction breakthrough. J Cardiovasc Electrophysiol 2003; 14:663-6. [PMID: 12875430 DOI: 10.1046/j.1540-8167.2003.03049.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Epicardial RFA to Achieve Electrical PV Isolation. During catheter ablation of atrial fibrillation, ablation within the pulmonary veins is undesirable due to the risk of pulmonary venous stenosis and the possibility of leaving residual cuffs of arrhythmogenic tissue proximal to the ablation lesion set. An extra-ostial pulmonary vein isolation strategy may circumvent these limitations, but achieving electrical isolation can be technically challenging, even with the use of saline-irrigated radiofrequency energy technology. This report describes the successful use of epicardial radiofrequency ablation in a patient in whom endocardial irrigated radiofrequency ablation failed to achieve extra-ostial pulmonary vein isolation.
Collapse
Affiliation(s)
- Vivek Y Reddy
- Cardiac Arrhythmia Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts 02114, USA.
| | | | | |
Collapse
|
196
|
Strobel JS. Electrocardiographic characteristics of ventricular arrhythmias arising from the aortic sinuses of valsalva: a case report and review of the literature. J Interv Card Electrophysiol 2002; 7:203-7. [PMID: 12510130 DOI: 10.1023/a:1021375628767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We describe a patient with frequent, symptomatic, and drug-refractory premature ventricular contractions (PVCs) with a right bundle branch block, inferior axis morphology suggestive of a left ventricular outflow tract (LVOT) origin. Successful ablation of the PVCs was performed from the left coronary cusp of the aortic valve. We discuss our patient and review the literature regarding patients with ventricular arrhythmias arising from the coronary cusps, with special emphasis on the use of the electrocardiogram to aid localization of the focus.
Collapse
Affiliation(s)
- John S Strobel
- Indiana University School of Medicine, Indianapolis, IN, USA.
| |
Collapse
|
197
|
|
198
|
Friedman PA, Asirvatham SJ, Grice S, Glikson M, Munger TM, Rea RF, Shen WK, Jahanghir A, Packer DL, Hammill SC. Noncontact mapping to guide ablation of right ventricular outflow tract tachycardia. J Am Coll Cardiol 2002; 39:1808-12. [PMID: 12039496 DOI: 10.1016/s0735-1097(02)01864-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES [corrected] The aim of this study was to determine whether noncontact mapping is feasible in the right ventricle and assess its utility in guiding ablation of difficult-to-treat right ventricular outflow tract (RVOT) ventricular tachycardia (VT). BACKGROUND In patients without inducible arrhythmia, RVOT VT may be difficult to ablate. Noncontact mapping permits ablation guided by a single tachycardia complex, which may facilitate ablation of difficult cases. However, the mapping system may be geometry-dependent, and it has not been validated in the unique geometry of the RVOT. METHODS Ten patients with left bundle inferior axis VT, no history of myocardial infarction and normal left ventricular function underwent noncontact guided ablation; seven had failed previous ablation and three had received a defibrillator. All noncontact maps were analyzed by a blinded reviewer to determine whether the arrhythmia focus was epicardial and to predict on the basis of the map whether arrhythmia would recur. RESULTS The procedure was acutely successful in 9 of 10 patients. During a mean follow-up of 11 months, 7 of 9 patients remained arrhythmia-free. Both patients in whom the blinded reviewer predicted failure had arrhythmia recurrence: one due to epicardial origin with multiple endocardial exit sites and one due to discordance between site of lesion placement and earliest activation on noncontact map. CONCLUSIONS Mechanisms of ablation failure in RVOT VT include absence of sustained arrhythmia, difficulty with substrate localization and epicardial origin of arrhythmia. In this study, noncontact mapping was safely and effectively used to guide ablation of patients with difficult-to-treat RVOT VT.
Collapse
Affiliation(s)
- Paul A Friedman
- Division of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
199
|
Ouyang F, Fotuhi P, Ho SY, Hebe J, Volkmer M, Goya M, Burns M, Antz M, Ernst S, Cappato R, Kuck KH. Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp: electrocardiographic characterization for guiding catheter ablation. J Am Coll Cardiol 2002; 39:500-8. [PMID: 11823089 DOI: 10.1016/s0735-1097(01)01767-3] [Citation(s) in RCA: 450] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to investigate the electrocardiographic (ECG) characteristics for guiding catheter ablation in patients with repetitive monomorphic ventricular tachycardia (RMVT) originating from the aortic sinus cusp (ASC). BACKGROUND Repetitive monomorphic ventricular tachycardia can originate from the right ventricular outflow tract (RVOT) and ASC in patients with a left bundle branch block (LBBB) morphology and an inferior axis. METHODS Activation mapping and ECG analysis was performed in 15 patients with RMVT or ventricular premature contractions. The left main coronary artery (LMCA) was cannulated as a marker and for protection during radiofrequency delivery if RMVT originated from the left coronary ASC. RESULTS During arrhythmia, the earliest ventricular activation was recorded from the superior septal RVOT in eight patients (group 1) and from the ASC in the remaining seven patients (group 2). The indexes of R-wave duration and R/S-wave amplitude were significantly lower in group 1 than in group 2 (31.8+/-13.5% vs. 58.3+/-12.1% and 14.9+/-9.9% vs. 56.7+/-29.5%, respectively; p < 0.01), despite similar QRS morphology. In five patients from group 2, RMVT originated from the left ASC, with a mean distance of 12.2+/-3.2 mm (range 7.3 to 16.1) below the ostium of the LMCA. In the remaining two patients, the RMVT origin was in the right ASC. All arrhythmias were successfully abolished. None of the patients had recurrence or complications during 9+/-3 months of follow-up. CONCLUSIONS On the surface ECG, RMVT from the ASC has a QRS morphology similar to that of RVOT arrhythmias. The indexes of R-wave duration and R/S-wave amplitude can be used to differentiate between the two origins. Radiofrequency ablation can be safely performed within the left ASC with a catheter cannulating the LMCA.
Collapse
Affiliation(s)
- Feifan Ouyang
- II. Med. Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|