Ventricular Outflow Tract Tachycardia Research Articles

Arrhythmogenic right ventricular dysplasia masquerading as right ventricular outflow tract tachycardia

Introduction: Ventricular tachycardia is a frequent complication in patients affected by arrhythmogenic right ventricular dysplasia. the disease is characterized by malignant ventricular arrhythmias with poor outcome, right ventricular dilation and replacement of the myocardium with fatty and fibrous tissue. On the other hand, right ventricular outflow tract tachycardia does not appear to have any significant effect on cardiac mortality as it arises in the absence of any structural heart disease. case report: Herein, we discussed a 62-year-old female patient with ventricular tachycardia that suggested right ventricular outflow tract tachycardia. based on echocardiography, electrophysiological study and magnetic resonance imaging the final diagnosis was arrhythmogenic right ventricular dysplasia. During electrophysiological study two ventricular

Aortic Sinus of Valsalva Aneurysm Isolation by Radiofrequency Ablation in Outflow Tract Ventricular Tachycardia

Idiopathic monomorphic ventricular tachycardia and premature ventricular complexes (PVCs) commonly arise from the right and left ventricular outflow tracts (VOT). Their mechanism is most commonly triggered activity from delayed after-depolarizations and successful ablation is performed at the site of earliest endocardial activation. Re-entrant mechanisms have been rarely described. We report a case of an otherwise healthy patient who ultimately underwent six electro-physiology studies (EPS) and suffered numerous implantable cardiac defibrillator (ICD) discharges prior to the successful radiofrequency ablation (RFA) of two idiopathic VOT tachycardias. During the sixth EPS, a proximal aortogram demonstrated a left aortic sinus of valsalva (LASV) aneurysm. Subsequntly, a novel and successful RFA strategy of aneurysm isolation was undertaken. The presence of multiple clinical or inducible VT morphologies and the characterization of a VT as re-entrant should raise concerns that a complex arrhythmogenic substrate is present and defining the anatomy with angiography or an alternative imaging modality is essential in achieving a successful ablation strategy.

Reentrant Ventricular Tachycardia Originating From the Periaortic Region in the Absence of Overt Structural Heart Disease

In the absence of overt structural heart disease, most left ventricular outflow tract ventricular tachycardias (VTs) have a focal origin and are benign. We hypothesized that multiple morphologies (MMs) of inducible left ventricular outflow tract VT may indicate a scar-related VT that can mimic idiopathic VT. Of 54 consecutive patients referred for ablation of sustained outflow tract VT without overt structural heart disease, 24 had left ventricular outflow tract VT, 10 had MM VT, and 14 had a single VT (SM). The MM group were older (70.3±4.3 versus 53.9±15.9 years; P=0.004), had more hypertension (100% versus 29%; P=0.0006), and had longer PR intervals and QRS durations compared with the SM group. In contrast to the SM group, the MM group VTs had features consistent with reentry, including induction by programmed stimulation without isoproterenol, entrainment in some, and abnormal electrograms in the periaortic area. Periaortic region voltages suggested scar in the MM group, but not in the SM group. MRI in 2 MM patients was consistent with scar, but not in 10 SM patients. Longer radiofrequency applications were required in the MM group than in the SM group. At a median follow-up of 9.7 (3.0-32.0) months, recurrences tended to be more frequent in the MM group than in the SM group (70% versus 22%; P=0.07). VTs from small regions of periaortic scar can mimic idiopathic VT but are suggested by multiple VT morphologies and are more difficult to ablate. Whether these patients are at greater risk, as feared for other scar-related VTs, warrants further study.

Changing exits in ventricular outflow tract tachycardia

A 67-year-old man without structural heart disease underwent ablation for symptomatic premature ventricular contractions (PVCs). The 12-lead ECG was indicative of an origin in the right ventricular outflow tract (RVOT) with left bundle branch block morphology, inferior axis, monophasic R wave in the inferior leads, and precordial R/S transition between leads V3/V4 (Figure 1A: 12-lead ECG prior to ablation).

Ablation of right ventricular outflow tract tachycardia using a novel multipolar irrigated ablation catheter (nMARQ)

A 54-year-old man with a history of hypertension presented with sudden onset of palpitation, chest pain, and dizziness. Frequent runs of nonsustained broad complex tachycardia were captured on ambulance 3-lead electrocardiogram with an inferior axis, suggestive of outflow tract ventricular tachycardia (VT). VT resolved spontaneously on admission at the coronary care unit. Subsequent echocardiography revealed normal biventricular function with normal sized left and right ventricles and no significant valvular abnormality.

Comparison of the “Real-life” Diagnostic Value of Two Recently Published Electrocardiogram Methods for the Differential Diagnosis of Wide QRS Complex Tachycardias

The diagnostic values of the aVR lead or "Vereckei algorithm," and the lead II R-wave peak time (RWPT) criterion, recently devised for the differential diagnosis of wide QRS complex tachycardias (WCTs), were compared. A total of 212 WCTs (142 ventricular tachycardias [VTs], 62 supraventricular tachycardias [SVT], and eight preexcitation SVTs) from 145 patients with proven electrophysiologic diagnoses were retrospectively analyzed by seven examiners blinded to the electrophysiologic diagnoses. The overall test accuracy of the Vereckei algorithm was superior to that of the RWPT criterion (84.3% vs. 79.6%; p = 0.0003). The sensitivity of the Vereckei algorithm for VT diagnosis was greater than that of RWPT criterion (92.4% vs. 79.1%; p < 0.0001). The negative predictive value (NPV) for the Vereckei algorithm was also greater (77.8%; 95% confidence interval [CI] = 73.6% to 82.1%) than that of the RWPT criterion (61.6%; 95% CI = 57.6% to 65.6%). The specificity of the Vereckei algorithm was lower than that of the RWPT criterion (64.7% vs. 80.9%; p < 0.0001). The positive predictive value (PPV) was also lower for the Vereckei algorithm (86.4%; 95% CI = 84.4% to 88.4%) than for the RWPT criterion (90.9%; 95% CI = 89.1% to 92.8%). Incorrect diagnoses made by the Vereckei algorithm were mainly due to misdiagnosis of SVT as VT (65.7% of cases), and those made by the RWPT criterion were due to the more dangerous misdiagnosis of VT as SVT (72.5% of cases). The Vereckei algorithm was superior in overall test accuracy, sensitivity, and NPV for VT diagnosis and inferior in specificity and PPV to the RWPT criterion. All of these parameters were lower in "real life" than those reported by the original authors for each of the particular electrocardiographic methods.

Long Term Results of Radio Frequency Ablation of Right Ventricular Outflow Tract Tachycardia

Long Term Results of Radio Frequency Ablation of Right Ventricular Outflow Tract Tachycardia

Long-Term Effect of Continuing Sports Activity in Competitive Athletes With Frequent Ventricular Premature Complexes and Apparently Normal Heart

The long-term outcome of athletes with frequent ventricular premature complexes (VPCs) and apparently normal heart has not been fully clarified. To evaluate the clinical and prognostic significance of VPCs and the influence of continuing sports activity during follow-up, we studied 120 healthy athletes (96 men; median age 16 years) in whom frequent VPCs (>100 VPCs/24 hours) were discovered by chance during preparticipation screening. All athletes were followed up for a median of 84 months. During follow-up, 96 underwent serial 24-hour Holter recording and 62 underwent serial echocardiography. The median number of VPCs/24 hours on basal Holter was 3,760. During follow-up, 81 athletes continued sports activity, whereas 39 did not. No athlete died or developed overt heart disease. The median number of VPCs/24 hours decreased in both athletes who continued sports activity and those who did not (from 3,805 to 1,124, p <0.0001 and from 5,787 to 1,298, p <0.0001, respectively). During follow-up, left ventricular ejection fraction slightly decreased to <55% in 9 of 62 athletes who, in respect to the remaining 53, had more VPCs/24 hours both in the basal state (12,000 vs 3,880) and during follow-up (10,702 vs 1,368), and a longer follow-up (95 vs 36 months). In conclusion, (1) frequent VPCs in athletes without heart disease have a long-term benign prognostic significance, (2) sporting activity does not modify this benign outcome, (3) during follow-up, the burden of VPCs decreases whether or not subjects continue sports activity, and (4) in 14.5% of athletes, ejection fraction slightly decreases over time.

Outflow Tract Ventricular Tachycardia Mapped to the Coronary Arteries: Anatomical Correlates and Management Strategies

The coronary cusps have been well described as a successful site for ablation in patients with symptomatic outflow tract ventricular tachycardia. The earliest site of activation is rarely found at the ostia or into the main coronary arteries. The exact anatomic substrate, diagnostic characteristics, and therapeutic approaches for such instances are poorly understood. We retrospectively reviewed outflow tract ventricular arrhythmia (OTVA) ablations done at Mayo Clinic Rochester from 2003 to 2011 (total VT: 414; outflow tract VT: 106). Three cases were identified where the earliest site of activation was not within the cusp but rather at or within the coronary ostia (3/414 for all VT: 0.7%; 3/106 for all OTVT: 2.8%). In 1 patient, the left main coronary artery (LMCA) was found to have electrograms (EGMs) recorded with bipolar mapping that preceded activation in the cusps or the left ventricular outflow tract. In 2 cases, the right coronary ostium and proximal right coronary artery recorded the earliest signals. Intracardiac echocardiographic guidance was used to successfully ablate these arrhythmias targeting the aortic route (1 patient) or the right coronary cusp (2 patients), and essentially isolated the focus of origin from the ventricular outflow tracts. Detailed mapping of surrounding structures, including the atrial appendages, the contralateral outflow tract, and the coronary venous system excluded far-field mapping in the artery as a cause for early activation at the ostial location. Local EGM characteristics suggested an unusually lengthy supravalvar myocardial extension as the likely arrhythmogenic substrate. Ablation was successful without coronary arterial or valvular injury and without valvular or root stenosis. Endocardial ablation isolating foci of origin in the vicinity of the coronary ostia is a challenging procedure but can be performed safely with appropriate visualization and is effective in the treatment of OTVA.

Autonomic Dysfunction in Patients with Arrhythmogenic Right Ventricular Cardiomyopathy: Biochemical Evidence of Altered Signaling Pathways

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an important cause of sudden cardiac death especially in times of increased sympathetic tone, for example, during sports, which have been confirmed by nuclear imaging studies. However, the underlying biochemical pathways remain to be delineated. Therefore, we investigated the expression levels of proteins of the signaling cascade in patients with ARVC. During diagnostic work-up, right ventricular endomyocardial biopsies (EMBs) were sampled from 15 consecutive male ARVC patients (52 ± 14 years). Tissue levels of key proteins of the signaling cascade were analyzed. Results were compared to those obtained from EMBs of 10 patients with idiopathic right ventricular outflow-tract tachycardia (RVOT; 41 ± 14 years) and of five control subjects without identifiable structural heart disease (42 ± 13 years; P = ns). Among the proteins analyzed, only tissue levels of norepinephrine (NE; P < 0.04) and cyclic adenosine-3´,5´-monophospate (cAMP; P < 0.01) were significantly lower in ARVC when compared to RVOT patients. When compared to controls, mean cAMP levels were lower in patients with ARVC but did not reach statistical significance. No differences in cAMP were observed between RVOT and controls. The current findings confirm and expand the concept of adrenergic dysfunction in ARVC: the reduction of NE in ARVC could lead to an impaired stimulation of β-adrenoceptor subsequent signaling pathways with potential implication for cardiac fibrosis and arrhythmogenesis.

GW24-e2281 Magnetic versus manual catheter navigation for mapping and ablation of right ventricular outflow tract ventricular arrhythmias: a randomised controlled study

ObjectivesThere has been no randomised controlled study to prospectively compare the performance and clinical outcomes of remote magnetic control (RMC) versus manual catheter control (MCC) during ablation of right ventricular...

GW24-e3925 The R-wave deflection interval in lead V3 combining with R-wave amplitude index in lead V1: A new surface ECG algorithm for distinguishing left from right ventricular outflow tract tachycardia origin in patients with transitional lead at V3

ObjectivesTo distinguish left ventricular outflow tract (LVOT) from right ventricular outflow tract (RVOT) origin in idiopathic premature ventricular contractions or ventricular tachycardia (PVCs/VT) patients with transitional lead at V3 is...

A shifting heart shifts the transition index

Numerous algorithms have been developed to assist localisation of outflow tract ventricular tachycardia (VT); however, they are all influenced by subtle differences in precordial and limb lead electrode placement. Another consideration is the cardiac location, even within the same patient as presented here. A syncopal young lady with ventricular outflow …

Ablação de arritmias da câmara de saída do ventrículo direito e esquerdo com sistema de navegação magnética por controlo remoto

ObjectiveThe aim of this study was to assess the efficacy and potential complications of a remote-controlled magnetic navigation system (Niobe II, Stereotaxis) for mapping and ablation of right or left ventricular outflow tract ventricular tachycardia or premature ventricular contractions. MethodsWe studied 32 consecutive patients, mean age 43±11 years, 24 female. Mapping of the arrhythmia was performed using the CARTO RMT mapping system, remotely guided by the Niobe II. Radiofrequency ablation was performed at the site of earliest ventricular activation with pacemapping of at least 11/12 leads.Acute success was defined as suppression and non-inducibility of the arrhythmia after stimulation with isoprenaline. After a minimum 3-month follow-up, we assessed clinical success (absence of symptoms and suppression of the arrhythmia on Holter recording), defined as less than 50 premature ventricular contractions/24 hours. ResultsThe origin of the arrhythmia was in the right ventricular outflow tract in 28 patients (88%), in the left in three, and in the epicardium in one. Acute success was achieved in 26 patients (81%). Two patients underwent a second successful procedure, in one of which an epicardial approach was necessary. The overall clinical success rate, after two repeat procedures, was 88%. No complications occurred.There were two recurrences during a mean follow-up of 307±204 days. ConclusionThe Niobe II remote control system for mapping and ablation of ventricular outflow tract arrhythmias is effective and safe, and provides precise mapping and a high success rate, with no complications.

Remote magnetic navigation for mapping and ablation of right and left ventricular outflow tract arrhythmias

ObjectiveThe aim of this study was to assess the efficacy and potential complications of a remote-controlled magnetic navigation system (Niobe II, Stereotaxis) for mapping and ablation of right or left ventricular outflow tract ventricular tachycardia or premature ventricular contractions. MethodsWe studied 32 consecutive patients, mean age 43±11 years, 24 female. Mapping of the arrhythmia was performed using the CARTO RMT mapping system, remotely guided by the Niobe II. Radiofrequency ablation was performed at the site of earliest ventricular activation with pacemapping of at least 11/12 leads.Acute success was defined as suppression and non-inducibility of the arrhythmia after stimulation with isoprenaline. After a minimum 3-month follow-up, we assessed clinical success (absence of symptoms and suppression of the arrhythmia on Holter recording), defined as less than 50 premature ventricular contractions/24 hours. ResultsThe origin of the arrhythmia was in the right ventricular outflow tract in 28 patients (88%), in the left in three, and in the epicardium in one. Acute success was achieved in 26 patients (81%). Two patients underwent a second successful procedure, in one of which an epicardial approach was necessary. The overall clinical success rate, after two repeat procedures, was 88%. No complications occurred.There were two recurrences during a mean follow-up of 307±204 days. ConclusionThe Niobe II remote control system for mapping and ablation of ventricular outflow tract arrhythmias is effective and safe, and provides precise mapping and a high success rate, with no complications.

Magnetic versus manual catheter navigation for mapping and ablation of right ventricular outflow tract ventricular arrhythmias: A randomized controlled study

No randomized controlled study has prospectively compared the performance and clinical outcomes of remote magnetic control (RMC) vs manual catheter control (MCC) during ablation of right ventricular outflow tract (RVOT) ventricular premature complexes (VPC) or ventricular tachycardia (VT). The purpose of this study was to prospectively evaluate the efficacy and safety of using either RMC vs MCC for mapping and ablation of RVOT VPC/VT. Thirty consecutive patients with idiopathic RVOT VPC/VT were referred for catheter ablation and randomized into either the RMC or MCC group. A noncontact mapping system was deployed in the RVOT to identify origins of VPC/VT. Conventional activation and pace-mapping was performed to guide ablation. If ablation performed using 1 mode of catheter control was acutely unsuccessful, the patient crossed over to the other group. The primary endpoints were patients' and physicians' fluoroscopic exposure and times. Mean procedural times were similar between RMC and MCC groups. The fluoroscopic exposure and times for both patients and physicians were much lower in the RMC group than in the MCC group. Ablation was acutely successful in 14 of 15 patients in the MCC group and 10 of 15 in the RMC group. Following crossover, acute success was achieved in all patients. No major complications occurred in either group. During 22 months of follow-up, RVOT VPC recurred in 2 RMC patients. RMC navigation significantly reduces patients' and physicians' fluoroscopic times by 50.5% and 68.6%, respectively, when used in conjunction with a noncontact mapping system to guide ablation of RVOT VPC/VT.

Transvenous Radiofrequency Ablation Therapy in the Treatment of Arrhythmias: A Single Center Experience

Giriş: Radyofrekans ablasyon taşiaritmilerin tedavisinde etkin bir yöntemdir. Bizler bu çalışmada taşikardilerin tedavisinde radyofrekans kateter ablasyonunun sonuçlarını araştırdık. Hastalar ve Yöntem: Aralık 2010 ile Ocak 2012 tarihleri arasında invaziv elektrofizyolojik girişim ve radyofrekans kateter ablasyonu yapılan ardışık semptomatik olan ve ilaç tedavisine dirençli atriyoventriküler nodal reentrant taşikardili 114 hasta, atriyoventriküler reentrant taşikardili (AVRT) 17 hasta (beş Wolf Parkinson White sendrom), atriyal taşikardili sekiz hasta, atriyal flattırlı yedi hasta, sağ ventrikül çıkış yolu kaynaklı taşikardisi olan beş hasta ve atriyal fibrilasyonu olan üç hasta çalışmaya dahil edildi. Bulgular: Taşikardisi olan 154 hastaya ablasyon tedavisi uygulandı (yaş: 39.1 ± 17.2 yıl, beden kitle indeksi: 24.3 ± 5.2 kg/m2, bel/kalça oranı: 0.88 ± 5.2, sistolik kan basıncı: 128.3 ± 22.4 mmHg, diyastolik kan basıncı: 75.30 ± 9.0 mmHg, dinlenme kalp hızı: 76.10 ± 8.2 beat/ dakika, 89 kadın 65 erkek). İşlem ve floroskopi süreleri sırasıyla 57.5 ± 19.0 ve 14.4 ± 4.1 dakikaydı. Ortalama takip süresi 10.2 ± 4.3 aydı. Takip süresince atriyoventriküler nodal reentrant taşikardili üç, atriyoventriküler reentrant taşikardili iki, sağ ventrikül çıkış yolu taşikardili bir ve atriyal fibrilasyonlu bir hastada rekürrens gelişti. Sonuç: Transvenöz radyofrekans ablasyon tedavisi deneyimli ellerde taşiaritmilerin tedavisi için güvenli ve etkin bir yöntemdir.

流出路心室頻拍を合併した大動脈弁輪拡張症に対しBentall手術と高周波アブレーションを行った1例

流出路心室頻拍を合併した大動脈弁輪拡張症に対しBentall手術と高周波アブレーションを行った1例

Positive QRS Complex in Lead I as a Malignant Sign in Right Ventricular Outflow Tract Tachycardia

Idiopathic ventricular fibrillation (VF) or polymorphic ventricular tachycardia (PVT) arising from the right ventricular outflow tract (RVOT) is occasionally observed. The difference in the initial ventricular premature contraction (VPC) between VF/PVT and monomorphic VT (MVT) from the RVOT, however, has not yet been fully investigated. The electrocardiogram findings and the clinical characteristics were compared between 14 patients with PVT and 77 with MVT. The episodes of syncope were more frequent in the VF and/or PVT group (57%) than in the MVT group (10%). An initial VPC with a positive QRS complex in lead I was observed in 10 (71%) of 14 patients with VF/PVT, and in 27 (35%) of 77 patients with MVT (P<0.05). Although radiofrequency (RF) catheter ablation targeting the trigger VPC often produced a morphological change, VF/PVT was eliminated in 13 (93%) of 14 patients after additional RF applications. Malignant arrhythmias from the RVOT, although rare, should be considered when the patient has a syncopal episode and VPC with a positive QRS complex in lead I.

The R-wave deflection interval in lead V3 combining with R-wave amplitude index in lead V1: A new surface ECG algorithm for distinguishing left from right ventricular outflow tract tachycardia origin in patients with transitional lead at V3

To distinguish left ventricular outflow tract (LVOT) from right ventricular outflow tract (RVOT) origin in idiopathic premature ventricular contractions or ventricular tachycardia (PVCs/VT) patients with transitional lead at V3 is still a challenge. We sought to develop a new electrocardiography (ECG) algorithm for distinguishing LVOT from RVOT origin in patients with idiopathic outflow tract PVCs/VT with precordial transitional lead at V3. We analyzed the surface ECG characteristics in a retrospective cohort of idiopathic PVCs/VT patients with transitional lead at V3 who underwent successful radiofrequency catheter ablation and developed a new surface ECG algorithm, then validated it in a prospective cohort. A total of 82 consecutive patients (47 ± 17 years, 39% male) underwent radiofrequency catheter ablation of idiopathic outflow tract PVCs/VT between January 2006 and August 2010. Among them, 31 patients (38%) with transitional lead at V3 constituted the retrospective cohort. Based on the areas under the receiver operating characteristic curves, R-wave deflection interval in lead V3>80 ms and R-wave amplitude index in lead V1>0.30 were selected to develop the new surface ECG algorithm. It correctly identified the origin sites of eleven from 12 patients in the prospective cohort, yielding the accuracy of 91.7%. We presented a new simple surface ECG algorithm, R-wave deflection interval in lead V3>80 ms combining with R-wave amplitude index in lead V1>0.30 which can reliably distinguish LVOT from RVOT origin in idiopathic outflow tract PVCs/VT in patients with transitional lead at V3.