Ventricular arrhythmias in patients with bicuspid aortic valves

Abstract

IntroductionBicuspid aortic valves (BAV) are the most common congenital heart defects and the extent of ventricular arrhythmias (VA) in patients with BAV is unclear. The objective of this study is to describe VAs and late gadolinium enhancement cardiac magnetic resonance imaging (LGE‐CMR) in patients with BAV.MethodsA total of 19 patients with BAV (18 males, age: 58 ± 13 years) were referred for VA ablation procedures. Ten patients had BAVs at the time of ablation, nine patients had prior aortic valve replacement for a BAV. All but one patient had LGE‐CMR and all patients underwent programmed ventricular stimulation at the time of the ablation.ResultsFrequent PVCs were the targeted VAs in 17/19 patients and VT in 2/19 patients. Monomorphic ventricular tachycardia (VT) was inducible in 6 patients. A total of 15 VTs were inducible (2.5 ± 1.0 VTs per patient with a mean cycle length of 322 ± 83 msec). LGE was present in 13 patients. Patients with inducible VT had larger borderzone and core scar compared to non‐inducible patients (7.8 ± 2.1 cm3 vs. 2.5 ± 3.1 cm3 and 5.1 ± 2.6 cm3 vs. 1.9 ± 3.0 cm3, p‐value < .05 for both). PVCs and VTs were mapped to the periaortic valve area in 12 patients and 4 patients, respectively. The PVC burden was reduced from 27 ± 13 to 3 ± 6 (p < .001) and the ejection fraction improved from 49 ± 13% to 55 ± 9% (p = .005).ConclusionsVAs in patients with BAV often originate from the perivalvular area and patients often have LGE and inducible VT. LGE may be due to ventricular remodeling secondary to the presence of BAV and harbors the arrhythmogenic substrate for VT.

Unique feature of ventricular arrhythmia in patients with bicuspid aortic valve

“…To the Editor, Ghannam and colleagues investigated the features of ventricular arrhythmia in patients with bicuspid aortic valve (BAV). 1 They demonstrated that ventricular arrhythmia in this cohort often originates from the peri-valvular area and those with BAV often had late gadolinium enhancement (LGE) and inducible ventricular tachycardia. Several concerns have been raised.…”

“…The authors' study included 10 patients with BAV who received no valvular interventions and 9 patients who had received aortic valve replacement for BAV. 1 The extra-valvular injury is staged according to the disease progression, ranging from left ventricle alone to mitral valve, left atrium, pulmonary vasculature, and right ventricle. 2 Thus, the severity of aortic stenosis may have a significant impact on the distribution and degree of myocardial injury as well as the burden of ventricular arrhythmia.…”

“…In the authors' study, patients with BAV had LGE at the peri-valvular area. 1 However, ventricular arrhythmia often originates from the left ventricular outflow in patients with nonischemic cardiomyopathy. 3 Hemodynamic abnormality due to aortic stenosis, regardless of the number of aortic cusps, would trigger ventricular arrhythmia.…”

“…The authors reported the feasibility of radiofrequency ablation for the patients with BAV. 1 However, detailed procedures such as approach types remain unstated. For example, the retrograde approach has risks of vascular complication and thromboembolism, whereas the trans-septal approach has a limitation in ablating supravalvular lesions.…”