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Gonzalez ML, Sriram CS, Gonzalez MD. Irregular ventricular tachycardia originating from the moderator band. J Electrocardiol 2023; 78:25-28. [PMID: 36736059 DOI: 10.1016/j.jelectrocard.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/31/2023]
Abstract
Ventricular tachycardias (VT) may initially show beat to beat oscillations but rapidly stabilize into a regular tachycardia with a stable cycle length. A persistently irregular ventricular tachycardia is a rare phenomenon. We report a rare case of an "irregular" ventricular tachycardia with so pronounced oscillations in cycle length that it was initially misdiagnosed as atrial fibrillation with aberrant conduction. This ventricular tachycardia was incessant and resulted in a tachycardia induced cardiomyopathy refractory to several antiarrhythmic drugs. Mapping of the right ventricle demonstrated that the tachycardia had a focal origin in the moderator band close to its insertion into the anterior papillary muscle. Radiofrequency ablation eliminated the tachycardia with eventual normalization of left ventricular function. The moderator band and anterior papillary muscle of the right ventricle are known to be the source of short-coupled ventricular premature beats and regular ventricular tachycardias. However, an "irregular" ventricular tachycardia has not been previously reported to arise from these structures.
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Affiliation(s)
| | - Chenni S Sriram
- Division of Pediatric Cardiology/Electrophysiology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Mario D Gonzalez
- Division of Electrophysiology, Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Penn State University School of Medicine, Hershey, PA, USA.
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2
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Peretto G, Sala S, Basso C, Rizzo S, Radinovic A, Frontera A, Limite LR, Paglino G, Bisceglia C, De Luca G, Campochiaro C, Sartorelli S, Palmisano A, Esposito A, Busnardo E, Villatore A, Baratto F, Cireddu M, Marzi A, D'Angelo G, Gulletta S, Vergara P, De Cobelli F, Dagna L, Mazzone P, Della Bella P. Inflammation as a Predictor of Recurrent Ventricular Tachycardia After Ablation in Patients With Myocarditis. J Am Coll Cardiol 2021; 76:1644-1656. [PMID: 33004129 DOI: 10.1016/j.jacc.2020.08.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/27/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Little is known about the risk stratification of patients with myocarditis undergoing ventricular tachycardia (VT) ablation. OBJECTIVES This study sought to describe VT ablation results and identify factors associated with arrhythmia recurrences in a cohort of patients with myocarditis. METHODS The authors enrolled 125 consecutive patients with myocarditis, undergoing VT ablation. Before ablation, disease stage was evaluated, to identify active (AM) versus previous myocarditis (PM). The primary study endpoint was assessment of VT recurrences by 12-month follow-up. Predictors of VT recurrences were retrospectively identified. RESULTS All patients (age 51 ± 14 years, 91% men, left ventricular ejection fraction 52% ± 9%) had history of myocarditis diagnosed by endomyocardial biopsy (59%) and/or cardiac magnetic resonance (90%). Furthermore, all had multiple episodes of drug-refractory VTs. Multimodal pre-procedural staging identified 47 patients with AM (38%) and 78 patients with PM (62%). All patients showed low-voltage areas (LVA) at electroanatomical map (97% epicardial or endoepicardial); of them, 25 (20%) had wide borderzone (WBZ, constituting >50% of the whole LVA). VT recurrences were documented in 25 patients (20%) by 12 months, and in 43 (34%) by last follow-up (median 63 months; interquartile range: 39 to 87). At multivariable analysis, AM stage was the only predictor of VT recurrences by 12 months (hazard ratio: 9.5; 95% confidence interval: 2.6 to 35.3; p < 0.001), whereas both AM stage and WBZ were associated with arrhythmia recurrences anytime during follow-up. No VT episodes were found after redo ablation was performed in 23 patients during PM stage. CONCLUSION Our findings suggest that VT ablation should be avoided during AM, but is often of benefit for recurrent VT after the acute phase of myocarditis.
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Affiliation(s)
- Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy; San Raffaele Vita-Salute University, Milan, Italy.
| | - Simone Sala
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Basso
- Department of Cardiovascular Pathology, Padua Hospital and University, Padua, Italy
| | - Stefania Rizzo
- Department of Cardiovascular Pathology, Padua Hospital and University, Padua, Italy
| | - Andrea Radinovic
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Frontera
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Rosario Limite
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Paglino
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Caterina Bisceglia
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo De Luca
- San Raffaele Vita-Salute University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Sartorelli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Palmisano
- San Raffaele Vita-Salute University, Milan, Italy; Experimental Imaging Center, Radiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Esposito
- San Raffaele Vita-Salute University, Milan, Italy; Experimental Imaging Center, Radiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena Busnardo
- Nuclear Medicine Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Francesca Baratto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Manuela Cireddu
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Marzi
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe D'Angelo
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simone Gulletta
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Vergara
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco De Cobelli
- San Raffaele Vita-Salute University, Milan, Italy; Experimental Imaging Center, Radiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Dagna
- San Raffaele Vita-Salute University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy; San Raffaele Vita-Salute University, Milan, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy; San Raffaele Vita-Salute University, Milan, Italy
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Peretto G, Barison A, Forleo C, Di Resta C, Esposito A, Aquaro GD, Scardapane A, Palmisano A, Emdin M, Resta N, Santoni A, Guaricci AI, Santobuono VE, Pepe M, Favale S, Ferrari M, Benedetti S, Della Bella P, Sala S. Late gadolinium enhancement role in arrhythmic risk stratification of patients with LMNA cardiomyopathy: results from a long-term follow-up multicentre study. Europace 2020; 22:1864-1872. [DOI: 10.1093/europace/euaa171] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/26/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Aims
We aimed at addressing the role of late gadolinium enhancement (LGE) in arrhythmic risk stratification of LMNA-associated cardiomyopathy (CMP).
Methods and results
We present data from a multicentre national cohort of patients with LMNA mutations. Of 164 screened cases, we finally enrolled patients with baseline cardiac magnetic resonance (CMR) including LGE sequences [n = 41, age 35 ± 17 years, 51% males, mean left ventricular ejection fraction (LVEF) by echocardiogram 56%]. The primary endpoint of the study was follow-up (FU) occurrence of malignant ventricular arrhythmias [MVA, including sustained ventricular tachycardia (VT), ventricular fibrillation, and appropriate implantable cardioverter-defibrillator (ICD) therapy]. At baseline CMR, 25 subjects (61%) had LGE, with non-ischaemic pattern in all of the cases. Overall, 23 patients (56%) underwent ICD implant. By 10 ± 3 years FU, eight patients (20%) experienced MVA, consisting of appropriate ICD shocks in all of the cases. In particular, the occurrence of MVA in LGE+ vs. LGE− groups was 8/25 vs. 0/16 (P = 0.014). Of note, no significant differences between LGE+ and LGE− patients were found in currently recognized risk factors for sudden cardiac death (male gender, non-missense mutations, baseline LVEF <45% and non-sustained VT), all P-value >0.05.
Conclusions
In LMNA-CMP patients, LGE at baseline CMR is significantly associated with MVA. In particular, as suggested by this preliminary experience, the absence of LGE allowed to rule-out MVA at 10 years mean FU.
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Affiliation(s)
- Giovanni Peretto
- Department of Arrhythmology and Cardiac Electrophysiology, IRCCS San Raffaele Hospital, Milan, Italy
- San Raffaele Vita-Salute University, Milan, Italy
| | - Andrea Barison
- Department of Cardiovascular Imaging, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Cinzia Forleo
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Chiara Di Resta
- San Raffaele Vita-Salute University, Milan, Italy
- Genomic Unit for the Diagnosis of Human Pathologies, Division of Genetics and Cellular Biology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Antonio Esposito
- San Raffaele Vita-Salute University, Milan, Italy
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giovanni Donato Aquaro
- Department of Cardiovascular Imaging, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Arnaldo Scardapane
- Interdisciplinary Department of Medicine, Section of Radiology, University of Bari Aldo Moro, Bari, Italy
| | - Anna Palmisano
- San Raffaele Vita-Salute University, Milan, Italy
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michele Emdin
- Department of Cardiovascular Imaging, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Nicoletta Resta
- Division of Medical Genetics, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Anna Santoni
- Genomic Unit for the Diagnosis of Human Pathologies, Clinical Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andrea Igoren Guaricci
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Vincenzo Ezio Santobuono
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Martino Pepe
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Stefano Favale
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | | | - Sara Benedetti
- Laboratory of Clinical Molecular Biology and Cytogenetics, IRCCS San Raffaele Hospital, Milan, Italy
| | - Paolo Della Bella
- Department of Arrhythmology and Cardiac Electrophysiology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Simone Sala
- Department of Arrhythmology and Cardiac Electrophysiology, IRCCS San Raffaele Hospital, Milan, Italy
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Peyrol M, Sbragia P, Orabona M, Casalta AC, Laine M, Decourt A, Quatre A, Jacquier A, Siddo ND, Paganelli F. Ventricular allorhythmia during infarct-related ventricular tachycardia. J Electrocardiol 2012; 45:394-397. [DOI: 10.1016/j.jelectrocard.2012.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Indexed: 11/16/2022]
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Tada H, Hiratsuji T, Naito S, Kurosaki K, Ueda M, Ito S, Shinbo G, Hoshizaki H, Oshima S, Nogami A, Taniguchi K. Prevalence and Characteristics of Idiopathic Outflow Tract Tachycardia with QRS Alteration Following Catheter Ablation Requiring Additional Radiofrequency Ablation at a Different Point in the Outflow Tract. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:1240-9. [PMID: 15461714 DOI: 10.1111/j.1540-8159.2004.00615.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Subtle variations in QRS morphology occurs during idiopathic outflow tract ventricular tachycardia (OTVT), but no studies have clarified the prevalence and characteristics of the OTVT with altered QRS morphology following radiofrequency catheter ablation (RFA), which then require an additional RF application at a different portion of the outflow tract to abolish OTVT. Of 202 patients with a monomorphic VT or premature ventricular contraction (PVC) originating from the outflow tract, 6 (3%) showed changes in QRS morphology in the OTVT following RFA, requiring an additional RF application to the outflow tract at a different portion. In all six patients, RFA was applied for the first or second OTVT to a right or left ventricular endocardial site, with the other site being the left sinus of Valsalva. In each patient, OTVT before or after the changes in QRS morphology had characteristic ECG findings originating from a particular portion of the outflow tract. Changes in QRS morphology consistently included an increase or decrease in R wave amplitude in all inferior leads. Detailed continuous observation of QRS morphology in OTVT, especially R wave amplitude in inferior leads, is important for identifying changes of QRS morphology during catheter ablation. Mapping and ablation at a different portion of the outflow tract is then needed for cure.
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Affiliation(s)
- Hiroshi Tada
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan.
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Satullo G, Donato A, Cavallaro L. P-P Cycle Alternans During Atrial Tachycardia:. Ann Noninvasive Electrocardiol 2000. [DOI: 10.1111/j.1542-474x.2000.tb00374.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Chinushi M, Aizawa Y, Takahashi K, Kouji O, Kitazawa H, Washizuka T, Abe A, Shibata A. Morphological variation of nonreentrant idiopathic ventricular tachycardia originating from the right ventricular outflow tract and effect of radiofrequency lesion. Pacing Clin Electrophysiol 1997; 20:325-36. [PMID: 9058870 DOI: 10.1111/j.1540-8159.1997.tb06177.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
RF catheter ablation was performed in 16 patients with nonreentrant idiopathic VT originating from the RVOT. All documented VT was monomorphic, but subtle morphological variation in the VT-QRS complex was observed in 10 (63%) of 16 patients. Through endocardial mapping, VT origin was determined within a narrow site (< 0.5 x 0.5 cm) in 4 of the 10 patients with the morphological variation. In the other 6 of 10 patients, the origin extended to an area of > 0.5 x 0.5 cm. In VT with morphological variation, the local electrogram at the site of VT origin also showed variation in morphology and activation sequence. For VT of narrow origin, RF application to the site eliminated the VT. However, in VT from a wide arrhythmogenic area, RF current had to be delivered to 3-7 distinct sites to cover the possible origin, and specific QRS configuration of VT and/or PVC was ablated at each of the earliest activation site. All but one VT were successfully ablated by RF current. Subtle morphological variation was frequent in this type of VT, and about half were associated with a wide arrhythmogenic area. Precise mapping and analysis of the efficacy of each RF application might be helpful to better understand the relationship between subtle changes of VT-QRS morphology and their origins.
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Affiliation(s)
- M Chinushi
- First Department of Internal Medicine, Niigata University School of Medicine, Japan
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Washizuka T, Aizawa Y, Chinushi M, Naitoh N, Miyajima T, Kusano Y, Kitazawa H, Uchiyama H, Takahashi K, Shibata A. Alternation of QRS morphology and effect of radiofrequency ablation in idiopathic ventricular tachycardia. Pacing Clin Electrophysiol 1995; 18:18-27. [PMID: 7700826 DOI: 10.1111/j.1540-8159.1995.tb02471.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED We performed electrophysiological studies in 13 patients with idiopathic VT and attempted radiofrequency (RF) catheter ablation in 4 of them. RESULTS VT was induced by programmed stimulation in all patients and the mean cycle length was 363 +/- 58 msec. In 8 of 13 patients (62%), alternation of either the cycle length and/or morphology of VT was observed. Transient entrainment was achieved in all patients by rapid pacing from the right ventricular outflow tract so reentry was considered the underlying mechanism of VT. The site of earliest activation (EAS) during VT was located at the apicoposterior portion of the left ventricular septum and used as the target site for RF catheter ablation. Spikelike presystolic activity was detected 20-40 msec prior to the large deflection of the local electrogram in four patients. VT was terminated by a few seconds of RF current in all four patients, but subsequently new VTs with a slightly different morphology were induced in three of them and re-mapping showed a shift of the EAS. After additional RF ablation at the new EAS, VT was no longer induced. No complication was noted and VT did not recur during a follow-up period for a mean of 9.3 +/- 5.2 months. CONCLUSION RF catheter ablation seems useful and safe for idiopathic VT. The alternation of QRS morphology and the findings at the time of catheter ablation suggest that an alternative pathway or multiple exists may be present in some patients with idiopathic VT, because the change in VT morphology was associated with a shift of the EAS.
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Affiliation(s)
- T Washizuka
- First Department of Internal Medicine, Niigata University School of Medicine, Japan
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