Left Ventricular Outflow Tract Tachycardia With Preferential Conduction and Multiple Exits
2008; Lippincott Williams & Wilkins; Volume: 1; Issue: 2 Linguagem: Inglês
10.1161/circep.108.778563
ISSN1941-3149
AutoresTakumi Yamada, Michael Platonov, H. Thomas McElderry, G. Neal Kay,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 1, No. 2Left Ventricular Outflow Tract Tachycardia With Preferential Conduction and Multiple Exits Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBLeft Ventricular Outflow Tract Tachycardia With Preferential Conduction and Multiple Exits Takumi Yamada, Michael Platonov, H. Thomas McElderry and G. Neal Kay Takumi YamadaTakumi Yamada From the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Ala. , Michael PlatonovMichael Platonov From the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Ala. , H. Thomas McElderryH. Thomas McElderry From the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Ala. and G. Neal KayG. Neal Kay From the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Ala. Originally published1 Jun 2008https://doi.org/10.1161/CIRCEP.108.778563Circulation: Arrhythmia and Electrophysiology. 2008;1:140–142A 50-year-old man with idiopathic premature ventricular contractions (PVCs; PVC 1, Figure 1A) and ventricular tachycardias (VTs) was referred for catheter ablation. Activation and pace mapping were performed at multiple sites in the right and left ventricular outflow tracts (RVOT and LVOT) (Figure 1). Nonirrigated radiofrequency (RF) applications delivered in the left coronary cusp where pacing reproduced a perfect pace map failed to suppress PVCs but gave a slight change in the QRS morphology of the PVCs characterized by S waves in lead V6 (PVC 2, Figure 1B). VT with this altered QRS morphology was induced by programmed stimulation (VT 1, Figure 1B). Pacing in the distal great cardiac vein (GCV) reproduced a different QRS morphology (Figure 1D). During PVC 2, the earliest ventricular activation was observed at the aorto-mitral continuity (AMC) where pacing reproduced a perfect pace map (Figure 1B). However, nonirrigated RF applications at this site did not prevent the induction of multiple morphologies of VT with programmed stimulation (Figure 1). Those VT morphologies exhibited a fair match to the pace maps from the RVOT, GCV, and right coronary cusp (RCC) (VT 2, Figure 1C; VT 3, Figure 1D; and VT 4, Figure 1E, respectively). Gradual transition between 2 of those VT morphologies (VT 3 and VT 4) was observed, and the local ventricular activation in the GCV preceded the QRS onset during both of those VTs (Figure 2). The local ventricular activation in the GCV relative to that in the His bundle region was 35 ms earlier during VT 3 than VT 4 (Figure 2). Because RF applications in the GCV were limited by high impedance, epicardial mapping via a subxiphoid access was performed. However, no epicardial ventricular activation as early as in the GCV could be recorded. Very detailed endocardial and epicardial activation mapping of both the RVOT and LVOT during the multiple morphologies of VT revealed a consistently early activation in the AMC but variable activation times at remote sites. Finally, RF applications delivered to the medial AMC with an irrigated ablation catheter eliminated all the ventricular arrhythmias (VAs) (Figure 3). Download figureDownload PowerPointFigure 1. Twelve-lead electrocardiograms of VTs, PVCs, and pace maps (PMs), and a 3-dimensional computed tomography image showing the presumed ventricular arrhythmia origin (star), preferential conduction (dotted arrows), and exits identified by pace mapping. Ao indicates aorta; GCV, great cardiac vein; LA, left atrium; LCC, left coronary cusp; LV, left ventricle; RCC, right coronary cusp; and RVOT, right ventricular outflow tract.Download figureDownload PowerPointFigure 2. Cardiac tracings showing the spontaneous gradual conversions between the 2 VTs exhibiting a fair match to the pace map in the GCV and RCC. The first and second beats are fusion beats and the third and fourth and fifth to ninth beats are VTs exhibiting a fair match to the pace map in the GCV and RCC, respectively. Note that the ventricular activation in the His bundle (HB) region preceded the QRS onset during only the VT exhibiting a fair match to the pace map in the RCC and fusion beats of the 2 VTs. Xd,p indicates the distal and proximal electrode pairs of the X catheter. The other abbreviations are as in the previous figures.Download figureDownload PowerPointFigure 3. Successful ablation site. ABL indicates ablation catheter; LAO, left anterior oblique view; RAO, right anterior oblique view; RV, right ventricular catheter; and V-QRS, the local ventricular activation time relative to the QRS onset. The other abbreviations are as in the previous figures.In this case, a single intramural origin with a preferential conduction1 to multiple exit sites all over the RVOT and LVOT might have exhibited multiple VAs. No anatomic specificities other than an intramural origin were suggested because the QRS morphologies of all the VAs and their relevant pace maps were consistent with those of previous reports.2–4 Although all the exits were located in close proximity, the directions from the origin varied between rightward and leftward and between endocardial and epicardial. This case suggests that preferential conduction to multiple exits may occur anywhere in the LVOT. That property of preferential conduction in the LVOT may cause VAs with LVOT origins to exhibit variable ECG features and limit the accuracy of ECG algorithms to predict the site of a VA origin.DisclosuresDr Yamada is supported by a research grant from Boston Scientific and St. Jude Medical. Drs McElderry and Kay have participated in catheter research funded by Biosense-Webster and Irvine Biomedical. Dr Kay has received honoraria from Medtronic, Boston Scientific, and St. Jude Medical. The electrophysiology fellowship program at the University of Alabama at Birmingham receives funding support from Boston Scientific and Medtronic. Dr Platonov reports no conflicts.FootnotesCorrespondence to Takumi Yamada, MD, PhD, Division of Cardiovascular Disease, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd Ave S, Birmingham, AL 35294-0019. E-mail [email protected]References1 Yamada T, Murakami Y, Yoshida N, Okada T, Shimizu T, Toyama J, Yoshida Y, Tsuboi N, Muto M, Inden Y, Hirai M, Murohara T, McElderry HT, Epstein AE, Plumb VJ, Kay GN. Preferential conduction across the ventricular outflow septum in ventricular arrhythmias originating from the aortic sinus cusp. J Am Coll Cardiol. 2007; 50: 884–891.CrossrefMedlineGoogle Scholar2 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: 1280–1286.CrossrefMedlineGoogle Scholar3 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: 485–491.CrossrefMedlineGoogle Scholar4 Yamada T, McElderry HT, Doppalapudi H, Kay GN. Catheter ablation of ventricular arrhythmias originating from the vicinity of the His bundle: significance of mapping of the aortic sinus cusp. Heart Rhythm. 2008; 5: 37–42.CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Shah M, Liang J and Huntrakul A (2023) Optimal anesthesia approach during catheter ablation of premature ventricular complexes: you snooze, you lose!, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-023-01584-y Kong L, Shuang T, Li Z, Zou Z, Jiang W, Pu J and Wang X (2022) A Systemic Mapping Approach for Right and Left Parahisian Ventricular Arrhythmias Ablation, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2022.844320, 9 Yagyu S, Nagashima K, Wakamatsu Y, Otsuka N, Hayashida S, Kurokawa S, Hirata S and Okumura Y (2021) Three‐dimensional visualization of bidirectional preferential pathway conduction of premature ventricular contractions originating from the outflow tract, Journal of Cardiovascular Electrophysiology, 10.1111/jce.15014, 32:6, (1678-1686), Online publication date: 1-Jun-2021. 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Wang X, Kong L, Shuang T, Li Z, Zou Z, Jiang W and Pu J A Stepwise Approach for Ablation of Ventricular Arrhythmias Originating from the Parahisian Area, SSRN Electronic Journal, 10.2139/ssrn.3939437 June 2008Vol 1, Issue 2 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCEP.108.778563PMID: 19808404 Originally publishedJune 1, 2008 PDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-Defibrillator
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