Idiopathic Epicardial Left Ventricular Tachycardia Originating Remote From the Sinus of Valsalva

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 Ͼ10 mm from the ASOV. Coronary venous mapping demonstrated epicardial preceding endocardial activation by Ͼ10 ms (41Ϯ7 versus 15Ϯ11 ms before QRS onset; PϽ0.001). 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 Ն0.55 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 (PϽ0.001). Conclusions-Although

2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

“…Dlatego 12-odprowadzeniowe powierzchniowe EKG, w którym zarejestrowano kliniczny epizod VT, może ułatwić mapowanie i zabieg ablacji. U pacjentów z kardiomiopatią o etiologii innej niż niedokrwienna morfologia zespołów QRS może pozwolić na identyfikację tych pacjentów, u których prawdopodobnie wymagana będzie ablacja nasierdziowa [194][195][196][197]. Co więcej, przedzabiegowe obrazowanie za pomocą CMR może ułatwić nieinwazyjną identyfikację substratu arytmicznego u pacjentów z wywiadem zawału serca [198] lub u pacjentów z nasierdziowym VT [199].…”

“…W przybliżeniu w 70% przypadków źródłem jest RVOT [536]. Innymi miejscami powstawania arytmii są zatoki Valsalvy [537][538][539][540], LVOT [539][540][541], duże żyły serca [195,539,541] warstwa nasierdziowa mięśnia sercowego [195,539,541,542], przestrzeń między zastawką aortalną a mitralną [529,543] oraz, rzadko, pień płucny [544][545][546]. Idiopatyczny ogniskowy VT z drogi odpływu występuje zwykle u pacjentów bez strukturalnej choroby serca, ale u niektórych pacjentów w CMR wykazano niewielkie nieprawidłowości ścian [547,548].…”

Idiopathic Sustained Epicardial Ventricular Tachycardia Originating from the Great Cardiac Vein

“…Ratio of the idiopathic outflow tract VT/PVCs originating from the epicardium are 9-13% [1][2][3]. The ECG characteristics of these tachycardia cases are described as follows: significantly greater R wave amplitude in the inferior leads, an S wave in lead I as part of an rS or QS pattern, and greater Q wave amplitude in aVL compared with aVR (ratio >1.4) [1][2][3]. In this case, ECG characteristics have shown almost the same criteria.…”

“…In addition, a Q wave in lead I more commonly identify VT from an epicardial origin compared with an endocardial site [1]. Daniels et al [3] reported that a delayed precordial maximum deflection index ≥0.55 confidently localized VT to the epicardium with a sensitivity of 100% and a specificity of 98%. Medical therapy and ablation are the options for management of these arrhythmias.…”

“…The majority of the patients can be successfully treated by this procedure. The transthoracic epicardial approach is recommended in cases in which standard ablation approaches have failed [3]. We performed ablation via the great cardiac vein because the previous ablation attempt via AVC in another hospital had failed.…”