Intramural Outflow Tract Ventricular Tachycardia

Chen, Hongwu; Shehata, Michael; Swerdlow, Charles D.; Ma, Wei; Xu, Gang; Yang, Bing; Chen, Minglong; Wang, Xunzhang

doi:10.1161/circep.114.001744

Cited by 22 publications

(12 citation statements)

References 4 publications

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“…47 A recent single-center trial found an intramural focus in 8% of patients with idiopathic VA. 48 Most intramural VAs originate from the interventricular septum between the RVOT and LVOT and can be successfully mapped and ablated by using thin 2.5Fr multielectrode catheters and 5Fr ablation catheters advanced via the septal perforating branches of the cardiac venous system. 48, 49 The septal perforating branches allow access to otherwise inaccessible sites of the septal myocardium; however, venous branches vary significantly in size and course, so venographic guidance should be used and coronary arteriography should be performed to improve the safety of this challenging approach.…”

Section: Intramural Origin Of Idiopathic Vasmentioning

confidence: 99%

See 1 more Smart Citation

Catheter Ablation of Idiopathic Ventricular Arrhythmias Arising From the Cardiac Outflow Tracts　– Recent Insights and Techniques for the Successful Treatment of Common and Challenging Cases –

Heeger

Hayashi

Kück

et al. 2016

Circ J

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Section: Intramural Origin Of Idiopathic Vasmentioning

confidence: 99%

“…47 The identification, mapping and RFCA of these idiopathic VAs may be challenging for the electrophysiologist and need special consideration. The following will focus on these rare, more challenging cases.…”

Section: Challenging Cases Of Idiopathic Vasmentioning

confidence: 99%

Catheter Ablation of Idiopathic Ventricular Arrhythmias Arising From the Cardiac Outflow Tracts　– Recent Insights and Techniques for the Successful Treatment of Common and Challenging Cases –

Heeger

Hayashi

Kück

et al. 2016

Circ J

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“…The foci are approximately equidistant between the triangular region formed by the great cardiac vein, the anterior aspect of the LCC, and the leftward aspect of the RVOT septum. 65 No electrocardiographic features reliably distinguish intra mural VT because preferential exit conduction can differ between patients. The diagnosis is confirmed when the earliest site of activation originates from a venous septal perforating branch of the great cardiac vein (or anterior interventricular vein) or, in cases where the perforator branch cannot be engaged, by identifying equally early sites with relatively diffuse activation on opposite sides of the interventricular septum.…”

Section: Intramural Originmentioning

confidence: 99%

“…Ablation is performed from the perforator or at the earliest site from both sides of the septum. 65,67,68 If the earliest site is adjacent to the bundle of His, cryoablation is the preferred energy source.…”

Section: Intramural Originmentioning

confidence: 99%

Mechanism, diagnosis, and treatment of outflow tract tachycardia

Lerman

2015

Nat Rev Cardiol

107

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Idiopathic ventricular arrhythmia is a generic term for a spectrum of arrhythmias that occur in the absence of structural heart disease or ion channelopathy. These arrhythmias include monomorphic premature ventricular contractions (PVCs), nonsustained monomorphic ventricular tachycardia (VT), and sustained VT. Most idiopathic ventricular arrhythmias originate from the right and left ventricular outflow tracts and include sites accessed from the aortic sinuses of Valsalva. Outflow tract arrhythmia is identified by an electrocardiographic pattern consistent with a left bundle branch block inferior axis morphology. Characteristically, outflow tract VT is caused by cAMP-mediated triggered activity, and is terminated by administration of adenosine. Outflow tract arrhythmias are focal and, therefore, are readily amenable to definitive treatment with catheter-based radiofrequency ablation. Although arrhythmia might be associated with reversible PVC-mediated cardiomyopathy, and infrequently with PVC-induced polymorphic VT or ventricular fibrillation, prognosis is generally favourable.

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“…Their well-constructed schematic sections are designed to be nonconventional views of looking at the regional anatomy of the intramural substrate. When studied along with the discussion of Chen et al, 1 we appreciate several nuances of what the epicardial surface, coronary veins, and arteries offer for mapping and access to this region.…”

Section: Ablating Intramural Substratementioning

confidence: 99%

Editor’s Perspective: In the Middle

Asirvatham

Stevenson

2014

Circ: Arrhythmia and Electrophysiology

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T he student of electrophysiology necessarily learns classic patterns and clear descriptions of anatomy and electrophysiology correlations to facilitate safe and effective invasive procedures. However, the same aid to learning serves as an obstacle when confronted with unusual arrhythmia manifestation that requires the appreciation of exceptions to the usual more simplistic constructs to succeed. In this segment of Teaching Rounds in Electrophysiology, Chen et al 1 describe 2 cases of intramural ventricular tachycardia arising from the outflow tract septum. They teach us with their precise approach for mapping and ablation how and when to break the rules we have learned and indeed use the uniqueness of the situation to solve the problem. Article see p 978What Is the Septum?The interventricular septum separates the right and left ventricles. We easily visualize the septum of the ventricular inflow portion, which is indeed central and between the right and left ventricular inflow tracts. Thus, in the left anterior oblique projection, if we have placed a catheter in the right ventricular inflow, then we know that moving the catheter leftward will allow contact on the septum. This construct, however, is not applicable to the septum of the ventricular outflow tracts. This is because the right ventricular outflow tract takes a complex course anteriorly and superficially to the left ventricular outflow tract with the pulmonic valve lying cephalad and leftward of the aortic valve.2,3 As a result, a catheter in the right ventricular outflow tract will need to be manipulated posteriorly to reach the ventricular septum, and moving leftward leads one closer to the left free wall portion of the right ventricular outflow tract near the pulmonic valve. The relationship, however, is a gradual change from the relatively midline inflow septum to the oblique and parallel-to-the-chest-wall course of the outflow tract septum. It is nearly impossible with fluoroscopy alone to identify which sites being mapped are actually septal. Intracardiac ultrasound or other imaging in real time is needed to appreciate that the myocardium being mapped or targeted for ablation is between the right and left ventricular chambers. What Is Intramural?Correlation among electrocardiography, anatomy, and a planned mapping and ablation approach for ventricular tachycardia presupposes that the right and left ventricles are distinct entities as is endocardial versus epicardial arrhythmogenic substrate. A focus or pathological tissue critical for reentrant tachycardia may reside intramurally and thus defy these clear distinctions. On the free wall of the left ventricle, intramural tissue represents the mid myocardial fibers that may be difficult to access from endovascular or subxiphoid pericardial approaches. On the septum, intramural tissue is complex, representing overlapping and intertwined myocardial fibers that can be traced to the right or left ventricular myocardium, and generally devoid of conduction tissue. Even more complex is the intramural subst...

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Intramural Outflow Tract Ventricular Tachycardia

Cited by 22 publications

References 4 publications

Catheter Ablation of Idiopathic Ventricular Arrhythmias Arising From the Cardiac Outflow Tracts　– Recent Insights and Techniques for the Successful Treatment of Common and Challenging Cases –

Catheter Ablation of Idiopathic Ventricular Arrhythmias Arising From the Cardiac Outflow Tracts　– Recent Insights and Techniques for the Successful Treatment of Common and Challenging Cases –

Mechanism, diagnosis, and treatment of outflow tract tachycardia

Editor’s Perspective: In the Middle

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Intramural Outflow Tract Ventricular Tachycardia

Cited by 22 publications

References 4 publications

Catheter Ablation of Idiopathic Ventricular Arrhythmias Arising From the Cardiac Outflow Tracts – Recent Insights and Techniques for the Successful Treatment of Common and Challenging Cases –

Catheter Ablation of Idiopathic Ventricular Arrhythmias Arising From the Cardiac Outflow Tracts – Recent Insights and Techniques for the Successful Treatment of Common and Challenging Cases –

Mechanism, diagnosis, and treatment of outflow tract tachycardia

Editor’s Perspective: In the Middle

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Product

Resources

About

Catheter Ablation of Idiopathic Ventricular Arrhythmias Arising From the Cardiac Outflow Tracts　– Recent Insights and Techniques for the Successful Treatment of Common and Challenging Cases –

Catheter Ablation of Idiopathic Ventricular Arrhythmias Arising From the Cardiac Outflow Tracts　– Recent Insights and Techniques for the Successful Treatment of Common and Challenging Cases –