RESUMEN
We present a rare case of reentrant ventricular tachycardia proven by entrainment maneuvers that was successfully ablated from the noncoronary cusp. The case highlights regional anatomy, pacing maneuvers with multi-modality images from fluoroscopy, intracardiac echo, and electroanatomical mapping.
Asunto(s)
Bloqueo de Rama/cirugía , Ablación por Catéter , Taquicardia Ventricular/cirugía , Potenciales de Acción , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Frecuencia Cardíaca , Humanos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenAsunto(s)
Potenciales de Acción , Bloqueo de Rama/diagnóstico , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Frecuencia Cardíaca , Taquicardia Paroxística/diagnóstico , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/cirugía , Ablación por Catéter , Diagnóstico Diferencial , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Taquicardia Paroxística/fisiopatología , Taquicardia Paroxística/cirugía , Factores de TiempoRESUMEN
BACKGROUND: Data characterizing structural changes of arrhythmogenic right ventricular (RV) cardiomyopathy are limited. METHODS: Patients presenting with left bundle branch block ventricular tachycardia in the setting of arrhythmogenic RV cardiomyopathy with procedures separated by at least 9 months were included. RESULTS: Nineteen consecutive patients (84% males; mean age 39±15 years [range, 20-76 years]) were included. All 19 patients underwent 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average 385±177 points per map; range, 93-847 points). Time interval between the initial and repeat ablation procedures was mean 50±37 months (range, 9-162). No significant progression of voltage was observed (bipolar: 38 cm2 [interquartile range (IQR), 25-54] versus 53 cm2 [IQR, 25-65], P=0.09; unipolar: 116 cm2 [IQR, 61-209] versus 159 cm2 [IQR, 73-204], P=0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase, 28%; 206 mL [IQR, 170-253] versus 263 mL [IQR, 204-294], P<0.001) for the entire study population. Larger scars at baseline but not changes over time were associated with a significant increase in RV volume (bipolar: Spearman ρ, 0.6965, P=0.006; unipolar: Spearman ρ, 0.5743, P=0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure. CONCLUSIONS: In patients with arrhythmogenic RV cardiomyopathy presenting with recurrent ventricular tachycardia, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent ventricular tachycardias are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with arrhythmogenic RV cardiomyopathy who have progressive RV dilation.
Asunto(s)
Displasia Ventricular Derecha Arritmogénica/diagnóstico por imagen , Displasia Ventricular Derecha Arritmogénica/cirugía , Mapeo del Potencial de Superficie Corporal/métodos , Ablación por Catéter/efectos adversos , Taquicardia Ventricular/diagnóstico por imagen , Adulto , Distribución por Edad , Anciano , Displasia Ventricular Derecha Arritmogénica/mortalidad , Bloqueo de Rama/diagnóstico por imagen , Bloqueo de Rama/mortalidad , Bloqueo de Rama/cirugía , Ablación por Catéter/métodos , Estudios de Cohortes , Técnicas Electrofisiológicas Cardíacas , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Recurrencia , Medición de Riesgo , Distribución por Sexo , Tasa de Supervivencia , Taquicardia Ventricular/epidemiología , Taquicardia Ventricular/etiología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: The ECG characteristics of the distal coronary venous system ventricular arrhythmias (VAs) share common features with VAs arising from the aortic cusps or the endocardial left ventricular outflow tract (LVOT) beneath the cusps. The purpose of this study was to identify specific electrocardiographic and electrophysiological characteristics of VAs originating from the distal great cardiac vein (GCV). METHODS: Based on the successful ablation site, patients with idiopathic VAs from the distal GCV, left coronary cusp (LCC) or the subvalvular left ventricular outflow tract (LVOT) area were included in the present study. RESULTS: The final population consisted of 39 patients (35 males, mean age 51 ± 23 years). All VAs displayed a right bundle branch block (RBBB) morphology with inferior axis. Among these patients, 15 were successfully ablated at the GCV, 15 at the LCC and 9 at the subvalvular region. A "w" pattern in lead I was present in 12 out of 15 (80%) VAs originating from the distal GCV compared to none of VAs arising from the other two sites (p < 0.01). VAs with a GCV origin exhibited more commonly increased intrinsicoid deflection time, higher maximum deflection index and wider QRS duration compared to LCC and subvalvular sites (p < 0.05). Acceptable pace mapping at the successful ablation site was achieved in 10 patients. After an average of 36 ± 24 months follow up, 14 (93.3%) patients were free from VAs recurrence. CONCLUSION: A "w" pattern in lead I may distinguish distal GCV VAs from VAs arising from the LCC or the subvalvular region.
Asunto(s)
Potenciales de Acción , Arritmias Cardíacas/diagnóstico , Bloqueo de Rama/diagnóstico , Seno Coronario/fisiopatología , Electrocardiografía , Ventrículos Cardíacos/fisiopatología , Adulto , Anciano , Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/cirugía , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/cirugía , Ablación por Catéter , Seno Coronario/cirugía , Técnicas Electrofisiológicas Cardíacas , Femenino , Frecuencia Cardíaca , Ventrículos Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Supervivencia sin Progresión , Factores de TiempoRESUMEN
BACKGROUND: While the left sinus of Valsalva (LSV) is a frequent origin of ventricular arrhythmias (VAs). Uncommonly, VAs with right bundle branch block (RBBB) morphology may be successfully terminated from the LSV. OBJECTIVE: We aimed to investigate the electrocardiographic and electrophysiologic characteristics of VAs with RBBB which were successfully eliminated from the LSV. METHODS: We identified patients with VAs successfully ablated from the LSV from January 2014 to December 2017 and compared electrophysiologic characteristics and ablation sites of those VAs with RBBB versus a control group of patients with left bundle branch block morphology. RESULTS: We identified 18 patients with RBBB and predominant "R" waves in the precordial leads. In 12 (66.7%) patients, a small "s" wave in lead V2 and positive "R" in the remaining pericardial leads could be seen. Overall, a single "V" potential was seen in 72.2% of patients in the study group, while discrete potentials were recorded in 80% of the patients in the control group. The majority (88.9%) of the VAs could only be terminated at the nadir of the LSV in the study group. After mean follow-up of 33 ± 14 months, 93.8% and 92% were free of VAs after initial ablation in study and control group, respectively (P = 0.99). CONCLUSION: Some VAs with predominant monophasic "R" wave in precordial leads could be terminated from LSV, especially a small "s" wave in lead V2 was recorded. The nadir of LSV is highly successful for RBBB VAs and single electrogram was recorded at the target for most of the cases.
Asunto(s)
Bloqueo de Rama/cirugía , Ablación por Catéter , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Frecuencia Cardíaca , Seno Aórtico/cirugía , Taquicardia Ventricular/cirugía , Complejos Prematuros Ventriculares/cirugía , Potenciales de Acción , Adulto , Anciano , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Ablación por Catéter/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Seno Aórtico/fisiopatología , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Resultado del Tratamiento , Complejos Prematuros Ventriculares/diagnóstico , Complejos Prematuros Ventriculares/fisiopatología , Adulto JovenRESUMEN
BACKGROUND: Patients with syncope and bundle branch block (BBB) are at risk for atrioventricular block (AVB). Electrophysiological study (EPS) can help in identifying patients at higher risk for AVB, but the false-negative rate is remarkable. Few data on the predictors of the need for pacemaker implantation during follow-up have been reported. OBJECTIVE: The purpose of this study was to analyze the rate of patients who need pacemaker implantation after negative EPS and predictive factors. METHODS: A single-center prospective study of 159 consecutive patients (73.9 ± 12.1 years; male 64.9%) with syncope and BBB (January 2012-December 2016) and negative EPS was conducted. An implantable loop recorder was implanted. RESULTS: After 27.9 ± 10.8 months of follow-up, 39 patients (24.8%) underwent pacemaker implantation because of bradyarrhythmia. In the univariate analysis, bifascicular (right BBB + left fascicular block) block, bifascicular block + long PR interval, conduction disturbance different from isolated right BBB, HV ≥60 ms, and HV ≥70 ms after class I drug challenge were predictors of pacemaker implantation. In the multivariate analysis, only bifascicular block (hazard ratio 2.5; 95% confidence interval 1.4-4.8; P = .04) and HV interval ≥60 ms (hazard ratio 3.5; 95% confidence interval 1.8-6.2; P <.001) were statistically significant. A risk score according to the multivariate model identified 3 levels of pacemaker implantation rate (13.5%, 32.7%, and 66.7%; P <.001). No death or severe trauma related to bradyarrhythmia occurred. CONCLUSION: The strategy of an implantable loop recorder in patients with syncope and BBB is safe after negative EPS, but some patients might need pacemaker implantation during follow-up. A risk score based on HV ≥60 ms and bifascicular block can be useful in identifying patients at risk for advanced AVB after negative EPS.
Asunto(s)
Bloqueo Atrioventricular , Bloqueo de Rama , Estimulación Cardíaca Artificial , Técnicas Electrofisiológicas Cardíacas , Marcapaso Artificial/estadística & datos numéricos , Medición de Riesgo , Síncope , Anciano , Bloqueo Atrioventricular/etiología , Bloqueo Atrioventricular/fisiopatología , Bloqueo Atrioventricular/prevención & control , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/cirugía , Estimulación Cardíaca Artificial/métodos , Estimulación Cardíaca Artificial/estadística & datos numéricos , Técnicas Electrofisiológicas Cardíacas/métodos , Técnicas Electrofisiológicas Cardíacas/normas , Reacciones Falso Negativas , Femenino , Estudios de Seguimiento , Sistema de Conducción Cardíaco/fisiopatología , Sistema de Conducción Cardíaco/cirugía , Humanos , Masculino , Valor Predictivo de las Pruebas , Pronóstico , Medición de Riesgo/métodos , Medición de Riesgo/estadística & datos numéricos , Síncope/diagnóstico , Síncope/etiología , Síncope/prevención & controlRESUMEN
BACKGROUND: The distinct electrophysiological features of bundle branch reentry ventricular tachycardia (VT) in patients without structural heart disease have not been systemically characterized. METHODS: Nine patients (mean age, 29.6 years) with normal left ventricular function were enrolled. Bundle branch reentry VT with right and left bundle branch block (BBB) patterns was induced in 1 and 9 patients, respectively. The right bundle was attempted to record by a 6F decapolar or quadripolar catheter. Electroanatomic mapping of the left ventricle was performed in 6 patients. In all left BBB pattern VT, the mean VT cycle length was 329.3±89.1 ms, and the median HV interval during tachycardia was longer than that of baseline (78 [73-100] versus 71 [64.5-88] ms; P=0.11). RESULTS: The H-RB interval during VT was slightly shorter (P=0.14); however, the median RB-V interval was markedly longer than that during sinus rhythm (50 [29.5-83] versus 30 [8-51] ms; P=0.043]. In 6 patients with 3-dimensional mapping of the left ventricle, a slow anterograde or retrograde conduction over left HIS-Purkinje system with normal myocardial voltage was identified. In addition, Purkinje-related VTs (1.0±1.3 types) were also induced in 5 patients. Ablation was applied in distal left BB in patients with baseline left BBB and in one narrow QRS patient with sustained Purkinje-related VT, whereas right BB was targeted in other patients. During a mean follow-up of 31.4 months, frequent premature ventricular contractions occurred in one patient, and new VT developed in the other patient. CONCLUSIONS: Bundle branch reentry VT can occur in young patients with extensive conduction disturbances within HIS-Purkinje system. Ablation targeting at the distal left BB which bifurcates into left posterior and anterior fascicle can preserve the residual atrioventricular conduction, but intensive follow-up is needed.
Asunto(s)
Potenciales de Acción , Fascículo Atrioventricular/fisiopatología , Bloqueo de Rama/diagnóstico , Técnicas Electrofisiológicas Cardíacas , Frecuencia Cardíaca , Ramos Subendocárdicos/fisiopatología , Taquicardia Ventricular/diagnóstico , Adolescente , Adulto , Fascículo Atrioventricular/cirugía , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/cirugía , Ablación por Catéter , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Ramos Subendocárdicos/cirugía , Taquicardia Ventricular/fisiopatología , Taquicardia Ventricular/cirugía , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Multiform fascicular tachycardia (FT) was recently described as a ventricular tachycardia (VT) that has a reentrant mechanism using multiple fascicular branches and produces alternate fascicular VT forms. Ablating the respective fascicle may cause a change in the reentrant circuit resulting in a change in morphology. Ablation of the septal fascicle is crucial for successful treatment. OBJECTIVES: To describe four cases of FT in which ablation induced a change in QRS morphologies and aggravated clinical course. METHODS: Four out of 57 consecutive FT cases at three institutions were retrospectively analyzed and found to involve multiform FT. These cases underwent electrophysiological study, fascicular potential mapping, and electroanatomical mapping. All patients initially had FT with right bundle branch block (RBBB) and superior axis morphology. RESULTS: Radiofrequency catheter ablation (RFCA) targeting the distal left posterior fascicle (LPF) resulted in a second VT with an RBBB-inferior axis morphology that sometimes became faster and/or incessant and/or verapamil-refractory in characteristics. RFCA in the upper septum abolished the second VT with no complications and uneventful long-term follow-up. CONCLUSIONS: The change in FT morphology during ablation may be associated with a change in clinical course when shifting from one route to another and may aggravate symptoms. Targeting of the proximal conduction system (such as bifurcation, LPF, left anterior fascicle, high septal/auxiliary pathway) may serve to solve this problem.
Asunto(s)
Fascículo Atrioventricular , Bloqueo de Rama , Ablación por Catéter/métodos , Técnicas Electrofisiológicas Cardíacas/métodos , Taquicardia Ventricular , Adulto , Fascículo Atrioventricular/fisiopatología , Fascículo Atrioventricular/cirugía , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/cirugía , Electrocardiografía/métodos , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiología , Taquicardia Ventricular/fisiopatología , Taquicardia Ventricular/prevención & control , Tiempo , Resultado del TratamientoRESUMEN
Objective: To explore the characteristics of electrocardiogram(ECG) and target potential features of premature ventricular contraction (PVC) in patients with complete left/right bundle branch block (CL/RBBB) and compare with those without CL/RBBB. Methods: A retrospective analysis was done in 8 outflow tract PVC patients with CL/RBBB, who successfully underwent radiofrequency ablation from August 2009 to June 2017. According to the bundle branch block chamber, patients were divided into the complete right bundle branch block (CRBBB) group (n=4) and the complete left bundle branch block (CLBBB) group (n=4). The control group were those who successfully underwent ablation at the same position as the above two groups but without CL/RBBB. The characteristics of ECG and target potential features were compared among groups. Results: One case in the CRBBB group was successfully ablated in the great cardiac vein with precordial R/S>1 transition at V(1) and one case in the CLBBB group was successfully ablated in the right coronary cusp with precordial R/S>1 transition at V(2), while other 6 cases were all with precordial R/S>1 transition at lead V(4). Precordial R/S>1 transition was not later than sinus rhythm (SR) in the CLBBB group. No statistical difference was found in the QRS complex duration between SR and PVC in the CL/RBBB patients [(134.38±23.80)ms vs (156.75±25.93)ms, P>0.05], while statistical difference was shown in the control group [(92.63±5.76)ms vs (140.25±15.97)ms, P<0.05]. Conclusion: Bundle branch block can lead to misjudgment of PVC origin with CL/RBBB during sinus rhythm, thus the origin chamber of the PVC should be determined according to the mapping and ablation result.
Asunto(s)
Bloqueo de Rama/diagnóstico , Bloqueo de Rama/cirugía , Complejos Prematuros Ventriculares/diagnóstico , Complejos Prematuros Ventriculares/cirugía , Ablación por Catéter/métodos , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Ventrículos Cardíacos , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
PURPOSE: Differentiation between idiopathic left posterior fascicular ventricular arrhythmias (LPF-VAs) and posterior papillary muscle (PPM) VAs is of clinical value. This study aimed to develop an algorithm to distinguish PPM-VAs from LPF-VAs. METHODS: This study enrolled 73 consecutive cases, including 31 with PPM-VAs and 42 with LPF-VAs, undergoing successful ablation by using 3D mapping and intracardiac echography to confirm the origin of the VAs. Electrocardiographic and electrophysiological parameters were compared between two groups. RESULTS: The 12-lead electrocardiography of the PPM-VAs was characterized by a longer QRS duration than that in LPF-VAs (154.4 ± 14.5 vs. 132.3 ± 13.1 ms, P < 0.001). A QRS duration ≥133 ms was observed in all patients (100%) with PPM-VAs and 13/42 (31.0%) patients with LPF-VAs. The conduction duration from the earliest left ventricular activation site of the VA to the proximal right bundle branch (VA-RBB) was longer in patients with PPM-VAs than LPF-VAs (51.3 ± 12.2 vs. 23.6 ± 7.7 ms, P < 0.001). Based on the ROC analysis, a VA-RBB >36 ms was recognized in 28/31 patients with PPM-VAs (90.3%) and 2/42 with LPF-VAs (4.8%). An algorithm incorporating a QRS duration of ≥133 ms with a conduction duration of a VA-RBB of >36 ms could yield a sensitivity of 90.3% and specificity of 100% for discriminating PPM-VAs from LPF-VAs. CONCLUSIONS: The novel algorithm incorporating a QRS duration of ≥133 ms with a conduction duration of the VA-RBB of >36 ms could be useful in differentiating PPM-VAs from LPF-VAs.
Asunto(s)
Bloqueo de Rama/cirugía , Ablación por Catéter/métodos , Electrocardiografía/métodos , Músculos Papilares/fisiopatología , Taquicardia Ventricular/diagnóstico por imagen , Taquicardia Ventricular/cirugía , Adulto , Bloqueo de Rama/diagnóstico por imagen , Estudios de Cohortes , Ecocardiografía/métodos , Técnicas Electrofisiológicas Cardíacas , Femenino , Sistema de Conducción Cardíaco/fisiopatología , Sistema de Conducción Cardíaco/cirugía , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Curva ROC , Recurrencia , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la EnfermedadRESUMEN
INTRODUCTION: In outflow tract ventricular arrhythmias (OT-VAs), an abrupt loss of the R wave in lead V2 compared to V1 and V3 (pattern break in V2-PBV2) suggests an origin close to the anterior interventricular sulcus (anatomically opposite to lead V2) and adjacent to proximal coronaries. We studied the outcome of catheter ablation of OT-VAs with a PBV2. METHODS AND RESULTS: Of 130 consecutive patients with idiopathic left bundle block morphology OT-VAs and transition ≤V4, 12 (9%) had PBV2. Outcomes in this group were compared to the remaining 118 patients. Patients with PBV2 were more likely to be younger (41 ± 18 vs. 50 ± 14 years, P = 0.0384) and women (11 [92%] vs. 70 [59%], P = 0.0302). The earliest activation was at the RVOT in seven, left coronary cusp (LCC) in one, anterior interventricular vein (AIV) in two and the epicardium in two. In five (42%) cases (earliest activation in the AIV in two, epicardium in two, and RVOT below the valve level in one), ablation was aborted due to proximity to the left anterior descending (LAD) coronary artery. After 36 ± 17 months and 1.3 ± 0.5 procedures, VAs elimination was achieved in 58% of patients with PBV2 compared to 89% of the reference population (P = 0.0125) with effective site in five of seven at the most anterior and leftward RVOT adjacent to the pulmonic valve (PV). CONCLUSIONS: OT-VAs with PBV2 demonstrate a unique ECG pattern and challenging catheter ablation. Proximity to LAD precludes ablation in about half. Long-term VA suppression could be achieved in only 58% of cases most commonly when the earliest site is at the anterior and leftward RVOT just under the PV.
Asunto(s)
Bloqueo de Rama/diagnóstico , Bloqueo de Rama/cirugía , Ablación por Catéter , Electrocardiografía , Ventrículos Cardíacos/cirugía , Potenciales de Acción , Adulto , Bloqueo de Rama/fisiopatología , Ablación por Catéter/efectos adversos , Técnicas Electrofisiológicas Cardíacas , Femenino , Frecuencia Cardíaca , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenAsunto(s)
Fascículo Atrioventricular/cirugía , Bloqueo de Rama/cirugía , Ablación por Catéter , Taquicardia Ventricular/cirugía , Potenciales de Acción , Adulto , Fascículo Atrioventricular/fisiopatología , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Frecuencia Cardíaca , Humanos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Resultado del TratamientoAsunto(s)
Potenciales de Acción , Bloqueo de Rama/cirugía , Ablación por Catéter , Sistema de Conducción Cardíaco/cirugía , Taquicardia Ventricular/cirugía , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Técnicas Electrofisiológicas Cardíacas , Femenino , Sistema de Conducción Cardíaco/fisiopatología , Frecuencia Cardíaca , Humanos , Persona de Mediana Edad , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Resultado del TratamientoAsunto(s)
Nodo Atrioventricular/fisiopatología , Bloqueo de Rama/diagnóstico , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Frecuencia Cardíaca , Complejos Prematuros Ventriculares/diagnóstico , Potenciales de Acción , Anciano , Nodo Atrioventricular/cirugía , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/cirugía , Estimulación Cardíaca Artificial , Ablación por Catéter , Diagnóstico Diferencial , Humanos , Masculino , Valor Predictivo de las Pruebas , Complejos Prematuros Ventriculares/fisiopatología , Complejos Prematuros Ventriculares/cirugíaRESUMEN
Major vessel injury during right ventricular outflow tract ablation is not something widely recognized, and routine evaluation of the left anterior descending (LAD) artery location in relation to the septal right ventricle is not routinely performed. In the present article, we report a case of acute LAD occlusion after right ventricular outflow tract ablation and then illustrate the intimately close relationship of the LAD artery to the anterior septal site of the RVOT (approximately 2-3 cm under the pulmonic valve), using a combination of intracardiac echocardiography and 3-dimensional electroanatomical mapping recorded during a second case, in order to specifically point to the area at risk.
Asunto(s)
Displasia Ventricular Derecha Arritmogénica/cirugía , Bloqueo de Rama/cirugía , Ablación por Catéter/efectos adversos , Oclusión Coronaria/etiología , Venas Pulmonares/cirugía , Taquicardia Ventricular/cirugía , Adulto , Displasia Ventricular Derecha Arritmogénica/diagnóstico , Displasia Ventricular Derecha Arritmogénica/fisiopatología , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Angiografía Coronaria , Oclusión Coronaria/diagnóstico por imagen , Ecocardiografía , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Humanos , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/fisiopatología , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Resultado del TratamientoAsunto(s)
Bloqueo de Rama/etiología , Cardiomiopatía Hipertrófica/complicaciones , Aneurisma Cardíaco/complicaciones , Frecuencia Cardíaca , Taquicardia Ventricular/etiología , Potenciales de Acción , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/cirugía , Estimulación Cardíaca Artificial , Cardiomiopatía Hipertrófica/diagnóstico , Ablación por Catéter , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Aneurisma Cardíaco/diagnóstico , Humanos , Persona de Mediana Edad , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Taquicardia Ventricular/cirugíaAsunto(s)
Bloqueo de Rama/cirugía , Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Ablación por Catéter/instrumentación , Irrigación Terapéutica/instrumentación , Complejos Prematuros Ventriculares/cirugía , Anciano , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Angiografía Coronaria , Seno Coronario/diagnóstico por imagen , Técnicas Electrofisiológicas Cardíacas , Diseño de Equipo , Humanos , Masculino , Radiografía Intervencional , Resultado del Tratamiento , Complejos Prematuros Ventriculares/diagnóstico , Complejos Prematuros Ventriculares/fisiopatologíaRESUMEN
Panoptic studies of ventricular tachycardia (VT) originating above the pulmonary valve are scarce. The purpose of this study is to clarify the characteristic of idiopathic VT arising above pulmonary valve. We analyzed 15 consecutive patients with idiopathic VT that was successfully abolished by catheter ablation at the right ventricular outflow tract (RVOT-VT, n = 11) and above the pulmonary valve (PA-VT, n = 4). Incidence of syncope was higher in PA-VT than RVOT-VT (100 vs 27 %, P < 0.05) and polymorphic VT was also more prevalent in PA-VT (75 vs 0 %, P < 0.05). The coupling interval (315 ± 29 vs 449 ± 32 ms, mean ± SE) at the onset of VT and minimum cycle length (CL) (192 ± 13 vs 344 ± 37 ms) during VT were shorter in PA-VT (both P < 0.05). Among 12-lead ECG parameters, only R-wave amplitude in lead II was different between groups (2.05 ± 0.17 mV in PA-VT vs 1.44 ± 0.05 mV in RVOT-VT, P < 0.005). At the successful ablation site, the activation time from the onset of QRS complex did not differ between groups (-37 ± 3 vs -31 ± 4, P = 0.405), whereas, the amplitude of intracardiac electrograms was significantly lower in PA-VT (0.83 ± 0.38 mV vs 2.39 ± 0.36 mV, P < 0.05). Although the number of patients in this study is limited, VT originating above the pulmonary valve demonstrated rapid excitation and often degenerated into polymorphic VT, suggesting its malignant electrophysiological characteristics.
Asunto(s)
Bloqueo de Rama/cirugía , Ablación por Catéter/métodos , Ventrículos Cardíacos/diagnóstico por imagen , Válvula Pulmonar/diagnóstico por imagen , Taquicardia Ventricular/fisiopatología , Adulto , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Ecocardiografía , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Válvula Pulmonar/fisiopatología , Estudios Retrospectivos , Taquicardia Ventricular/diagnósticoRESUMEN
BACKGROUND: Multiple intercostal recordings were supposed to get a more comprehensive view of the depolarization vector of the outflow tract ventricular arrhythmia (OT-VA), which may help to identify the OT-VA more accurately. This study was undertaken to develop a more accurate electrocardiogram (ECG) criterion for differentiating between left and right OT-VA origins. METHODS: We studied OT-VA with a left bundle branch block pattern and inferior axis QRS morphology in 47 patients with successful catheter ablation in the right ventricular OT (RVOT; n = 37) or aortic coronary cusp (ACC; n = 10). Superior and inferior precordial leads were taken together with the routine 12-lead ECG. The ECG during the OT-VA and during sinus beats were analyzed. Transition ratio, transition zone (TZ) index, R/S amplitude ratio, and R-wave duration ratio were measured in the regular, superior, and inferior precordial leads. RESULTS: The combined TZ index, TZ index inferior was significantly smaller, while the V2 inferior transition ratio was significantly larger for ACC origins than RVOT origins (P < 0.05). The area under the curve for the combined TZ index by a receiver operating characteristic analysis was 0.974, which was significantly larger than other parameters. A cutoff value ≤0.25 predicted an ACC origin with 94% sensitivity and 100% specificity. This advantage of the parameter over others also held true for a subanalysis of OT-VAs with a lead V3 precordial transition or TZ index = 0. CONCLUSIONS: The combined TZ index outperformed other ECG criteria to differentiate left from right OT-VA origins.
Asunto(s)
Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatología , Electrocardiografía/métodos , Ventrículos Cardíacos/fisiopatología , Arritmias Cardíacas/cirugía , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/cirugía , Ablación por Catéter , Diagnóstico Diferencial , Técnicas Electrofisiológicas Cardíacas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Accelerated idioventricular rhythm (AIVR) or ventricular tachycardia (VT) originating from the right bundle branch (RBB) is rare and published clinical data on such arrhythmia are scarce. In this study, we will describe the clinical manifestations, diagnosis, and management of a cohort of patients with this novel arrhythmia. METHODS AND RESULTS: Eight patients (5 men; median age, 25 years) with RBB-AIVR/VT were consecutively enrolled in the study. Pharmacological testing, exercise treadmill testing, electrophysiological study, and catheter ablation were performed in the study patients, and ECG features were characterized. All RBB-AIVR/VTs were of typical left bundle-branch block morphology with atrioventricular dissociation. The arrhythmias, which demonstrated chronotropic variability, were often isorhythmic with sinus rhythm and were accelerated by physical exercise, stress, and intravenous isoprenaline infusion. The rate of RBB-AIVR/VT varied from 45 to 200 beats per minute. Two patients experienced syncope, and 3 had impaired left ventricular function. Metoprolol was proven to be the most effective drug to decelerate the arrhythmia rate and relieve symptoms. Electrophysiology study was performed in 5 patients and the earliest activation with a sharp RBB potential was localized in the mid or distal RBB area. Catheter ablation terminated the arrhythmia with subsequent RBB block morphology during sinus rhythm. During follow-up, patients' symptoms were controlled with normalization of left ventricular function either on metoprolol or by catheter ablation. CONCLUSIONS: RBB-AIVR/VT is an unusual type of ventricular arrhythmia. It can result in significant symptoms and depressed ventricular function and can be successfully treated with catheter ablation.