Exercise provocable right ventricular outflow tract tachycardia

Abstract

During the past 5 years, we have seen six patients who met inclusion criteria of exertional palpitations, reproducible treadmill (TM) provocable ventricular tachycardia (VT), and performance of electrophysiologic (EP) studies including isoproterenol (ISO) infusion. There were five males and one female, aged 15 to 55 years (mean ± SD, 31 ± 18 years). Three patients were trained athletes, two patients had mitral valve prolapse, three had enlarged right ventricular (RV) volumes (all trained athletes), and two had no evidence of organic heart disease. TM testing in all patients demonstrated reproducible exercise-provocable VT of at least 20 beats' duration. TM VT was characterized by left bundle branch block pattern QRS morphology and rates of 150 to 230 bpm (186 ± 30 bpm). Ep did not reproduce VT in five of six patients while ISO at a dose of 2 to 4 μg/min (2.5 ± 0.8 μg/min) reproduced VT in all patients. ISO VT was characterized by QRS morphology identical to TM VT and rates of 165 to 230 bpm (191 ± 26 bpm). Endocardial mapping of ISO VT revealed earliest activity in RV outflow tract. Serial TM testing revealed suppression of TM VT in all six patients on propranolol therapy. Responses to class I drugs were variable and less successful. In summary, we describe a group of patients with common clinical, ECG, and electrophysiologic features who may share a common pathophysiology of VT. Possible mechanisms are discussed.