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Chevance V, Azarine A, Hamon DA, Dhanjal TS, Teiger E, Deux JF, Lellouche N. Wall shear stress in outflow tract premature ventricular contraction location assessed through 4D-flow MRI. Europace 2024; 26:euae034. [PMID: 38290435 PMCID: PMC10849830 DOI: 10.1093/europace/euae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/22/2024] [Indexed: 02/01/2024] Open
Affiliation(s)
- Virgile Chevance
- Radiology Department, Hopital Henri Mondor, APHP, Creteil, France
- Radiology Department, Centre Chirurgical Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Arshid Azarine
- Radiology Department, Centre Chirurgical Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - David A Hamon
- Cardiology and Electrophysiology Unit, Hopital Henri Mondor, APHP, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
- University of Iowa Hospitals and Clinics (UIHC), Department of Cardiology, Carver College of Medicine, Iowa City, IA
| | - Tarvinder S Dhanjal
- Department of Cardiac Electrophysiology, University of Warwick, Gibbet Hill, Coventry, UK
| | - Emmanuel Teiger
- Cardiology and Electrophysiology Unit, Hopital Henri Mondor, APHP, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
| | - Jean-François Deux
- Radiology Department, Hopital Henri Mondor, APHP, Creteil, France
- Radiology Department, University Hospitals of Geneva, Geneva, Switzerland
| | - Nicolas Lellouche
- Cardiology and Electrophysiology Unit, Hopital Henri Mondor, APHP, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
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2
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Penela D, Falasconi G, Carreño JM, Soto-Iglesias D, Fernández-Armenta J, Acosta J, Martí-Almor J, Benito B, Bellido A, Chauca A, Scherer C, Viveros D, Alderete J, Silva E, Ordoñez A, Francisco-Pascual J, Rivas-Gandara N, Meca-Santamaria J, Franco P, De Lucia C, Ali H, Cappato R, Cámara O, Francia P, Berruezo A. A hybrid clinical and electrocardiographic score to predict the origin of outflow tract ventricular arrhythmias. J Interv Card Electrophysiol 2023; 66:1877-1888. [PMID: 36795268 DOI: 10.1007/s10840-023-01507-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/04/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND To predict the outflow tract ventricular arrhythmias (OTVA) site of origin (SOO) before the ablation procedure has important practical implications. The present study sought to prospectively evaluate the accuracy of a clinical and electrocardiographic hybrid algorithm (HA) for the prediction of OTVAs-SOO, and at the same time to develop and to prospectively validate a new score with improved discriminatory capacity. METHODS In this multicenter study, we prospectively enrolled consecutive patients referred for OTVA ablation (N = 202), and we divided them in a derivation sample and a validation cohort. Surface ECGs during OTVA were analyzed to compare previous published ECG-only criteria and to develop a new score. RESULTS In the derivation sample (N = 105), the correct prediction rate of HA and ECG-only criteria ranged from 74 to 89%. R-wave amplitude in V3 was the best ECG parameter for discriminating LVOT origin in V3 precordial transition (V3PT) patients, and was incorporated to the novel weighted hybrid score (WHS). WHS correctly classified 99 (94.2%) patients, presenting 90% sensitivity and 96% specificity (AUC 0.97) in the entire population; WHS mantained a 87% sensitivity and 91% specificity (AUC 0.95) in patients with V3PT subgroup. The high discriminatory capacity was confirmed in the validation sample (N = 97): the WHS exhibited an AUC (0.93), and a WHS ≥ 2 allowed a correct prediction of LVOT origin in 87 (90.0%) cases, yielding a sensitivity of 87% and specificity of 90%; moreover, the V3PT subgroup showed an AUC of 0.92, and a punctuation ≥ 2 predicted an LVOT origin with a sensitivity of 94% and specificity of 78%. CONCLUSIONS The novel hybrid score has proved to accurately anticipate the OTVA's origin, even in those with a V3 precordial transition. A Weighted hybrid score. B Typical examples of the use of the weighted hybrid score. C ROC analysis of WHS and previous ECG criteria for prediction of LVOT origin in the derivation cohort. D ROC analysis of WHS and previous ECG criteria for prediction of LVOT origin in the V3 precordial transition OTVA subgroup.
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Affiliation(s)
- Diego Penela
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | - Giulio Falasconi
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
- University of Barcelona, Campus Clínic, Barcelona, Spain
| | - Jose Miguel Carreño
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | - David Soto-Iglesias
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | | | - Juan Acosta
- Virgen del Rocío University Hospital, Sevilla, Spain
| | - Julio Martí-Almor
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | - Begoña Benito
- Hospital Vall d'Hebron, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Aldo Bellido
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | - Alfredo Chauca
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | - Claudia Scherer
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | - Daniel Viveros
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
- University of Barcelona, Campus Clínic, Barcelona, Spain
| | - Jose Alderete
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
- University of Barcelona, Campus Clínic, Barcelona, Spain
| | | | - Augusto Ordoñez
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | | | | | | | - Paula Franco
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain
| | | | - Hussam Ali
- IRCCS Multimedica Group, Sesto San Giovanni, Italy
| | | | | | - Pietro Francia
- Cardiology, Department of Clinical and Molecular Medicine, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Antonio Berruezo
- Heart Institute, Teknon Medical Centre, C/ Vilana, 12; 08022, Barcelona, Spain.
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Zheng M, Deng KQ, Wang X, Luo D, Qu W, Chen C, Yu X, He W, Xie J, Jiang H, He B, Lu Z. Pulmonary Artery Denervation Inhibits Left Stellate Ganglion Stimulation-Induced Ventricular Arrhythmias Originating From the RVOT. JACC Clin Electrophysiol 2023; 9:1354-1367. [PMID: 37086230 DOI: 10.1016/j.jacep.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 01/20/2023] [Accepted: 02/15/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Electrical stimulation of the left stellate ganglion (LSG) can evoke ventricular arrhythmias (VAs) that originate from the right ventricular outflow tract (RVOT). The involvement of pulmonary artery innervation is unclear. OBJECTIVES This study investigated the effects of selective pulmonary artery denervation (PADN) on blood pressure (BP), sympathetic activity, ventricular effective refractory period (ERP), and the incidence of VAs induced by LSG stimulation in canines. METHODS Radiofrequency ablation with basic anesthetic monitoring was used to induce PADN in canines. In Protocol 1 (n = 11), heart rate variability, serum norepinephrine and angiotensin-II levels, BP changes and ventricular ERP in response to LSG stimulation were measured before and after PADN. In Protocol 2 (n = 8), the incidence of VAs induced by LSG stimulation was calculated before and after PADN in a canine model of complete atrioventricular block. In addition, sympathetic nerves in the excised pulmonary arteries were immunohistochemically stained with tyrosine hydroxylase. RESULTS The low-frequency components of heart rate variability, serum norepinephrine and angiotensin-II levels were remarkably decreased post-PADN. Systolic BP elevation and RVOT ERP shortening induced by LSG stimulation were mitigated by PADN. The number of RVOT-premature ventricular contractions as well as RVOT tachycardia episodes and duration induced by LSG stimulation were significantly reduced after PADN. In addition, a large number of tyrosine hydroxylase-immunoreactive nerve fibers were located in the anterior wall of the pulmonary artery. CONCLUSIONS PADN ameliorated RVOT ERP shortening, and RVOT-VAs induced by LSG stimulation by inhibiting cardiac sympathetic nerve activity.
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Affiliation(s)
- Meng Zheng
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China; Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan, China; Institute of Myocardial Injury and Repair, Wuhan University, Wuhan, China
| | - Ke-Qiong Deng
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China; Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan, China; Institute of Myocardial Injury and Repair, Wuhan University, Wuhan, China
| | - Xiaoying Wang
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China; Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan, China; Institute of Myocardial Injury and Repair, Wuhan University, Wuhan, China
| | - Da Luo
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Weiyi Qu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chao Chen
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaomei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wenbo He
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jing Xie
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bo He
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China; Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan, China; Institute of Myocardial Injury and Repair, Wuhan University, Wuhan, China.
| | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China; Cardiovascular Institute, Zhongnan Hospital of Wuhan University, Wuhan, China; Institute of Myocardial Injury and Repair, Wuhan University, Wuhan, China.
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4
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Idiopathic Ventricular Tachycardia. J Clin Med 2023; 12:jcm12030930. [PMID: 36769578 PMCID: PMC9918172 DOI: 10.3390/jcm12030930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/06/2023] [Accepted: 01/16/2023] [Indexed: 01/27/2023] Open
Abstract
Idiopathic ventricular tachycardia (VT) is an important cause of morbidity and less commonly, mortality in patients with structurally normal hearts. Appropriate diagnosis and management are predicated on an understanding of the mechanism, relevant cardiac anatomy, and associated ECG signatures. Catheter ablation is a viable strategy to adequately treat and potentially provide a cure in patients that are intolerant to medications or when these are ineffective. In this review, we discuss special approaches and considerations for effective and safe ablation of VT arising from the right ventricular outflow tract, left ventricular outflow tract, left ventricular fascicles, papillary muscles, and moderator band.
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5
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Parwani AS, Hohendanner F, Boldt LH. [Catheter ablation of ventricular tachycardia : Clinical outcome]. Herzschrittmacherther Elektrophysiol 2019; 30:349-355. [PMID: 31713027 DOI: 10.1007/s00399-019-00653-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/11/2019] [Indexed: 11/30/2022]
Abstract
Catheter-based ablation of ventricular tachycardia (VT) is increasingly used in clinical practice. The reported success rates are especially high in idiopathic VT. In randomized controlled clinical trials like VANISH, ablation of scar-associated VT was superior in terms of mortality when compared to antiarrhythmic therapy. Treatment at experienced centers, e.g., using state-of-the-art electroanatomical mapping systems, is a promising option for these complex and often multimorbid patients.
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Affiliation(s)
- Abdul S Parwani
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Felix Hohendanner
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Leif-Hendrik Boldt
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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Wang H, Zheng Z, Yao L, Mou Y, Wang X. Giant left ventricular pseudoaneurysm: a rare acute complication of radiofrequency catheter ablation for premature ventricular contraction. J Cardiothorac Surg 2019; 14:131. [PMID: 31272454 PMCID: PMC6610948 DOI: 10.1186/s13019-019-0946-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 06/20/2019] [Indexed: 11/25/2022] Open
Abstract
Background Radiofrequency catheter ablation is approved effective therapy for premature ventricular contraction. However, the rare but serious complication such as pseudoaneurysm should be given more attention. It is life-threatening due to the high risk of rupture. Only few cases have been reported in the literature. We herein report a huge acute left ventricular pseudoaneurysm after catheter ablation therapy. Case presentation A 69-year-old man underwent radiofrequency catheter ablation for premature ventricular contraction at a local hospital. The patient developed shock the second day after ablation. A chest computed tomography (CT) scan showed pericardial effusion. Pericardiocentesis was performed, and the puncture fluid was a bloody pericardial effusion. The transthoracic echocardiogram revealed an 9- × 4-cm giant pseudoaneurysm with a cystic structure in the left ventricular inferior wall near the mitral annulus along the left atrium. The pseudoaneurysm was connected to the left ventricular cavity through a 8-mm neck, and the lumen was filled with systolic and diastolic blood flow. The patient underwent three-dimensional transesophageal echocardiography. The pseudoaneurysm and the tract was clearly visible. Emergency surgery was performed to resect the pseudoaneurysm. A bovine pericardial patch was placed on the neck of the pseudoaneurysm. Echocardiographic examination confirmed the absence of cardiac lesions after the operation. Conclusions It is rare to see such a large pseudoaneurysm after radiofrequency catheter ablation. Clinicians should be allert to the potential risks to patients in the process of an effective treatment. Echocardiography plays an important role in the prompt diagnosis and prognosis of this disease. Emergency surgery is a better method for treatment of huge pseudoaneurysm. Electronic supplementary material The online version of this article (10.1186/s13019-019-0946-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hongxia Wang
- Echocardiography and Vascular Ultrasound Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zhelan Zheng
- Echocardiography and Vascular Ultrasound Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
| | - Lei Yao
- Echocardiography and Vascular Ultrasound Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yun Mou
- Echocardiography and Vascular Ultrasound Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiuqin Wang
- Echocardiography and Vascular Ultrasound Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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7
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Busch S, Eckardt L, Sommer P, Meyer C, Bonnemeier H, Thomas D, Neuberger HR, Tilz RR, Steven D, von Bary C, Kuniss M, Voss F, Estner HL. [Premature ventricular contractions and tachycardia in a structurally normal heart : Idiopathic PVC and VT]. Herzschrittmacherther Elektrophysiol 2019; 30:212-224. [PMID: 30767064 DOI: 10.1007/s00399-019-0607-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 01/21/2019] [Indexed: 06/09/2023]
Abstract
Premature ventricular contractions (PVC) are a common, often incidental and mostly benign finding. Treatment is indicated in frequent and symptomatic PVC or in cases of worsening of left ventricular function. Idiopathic ventricular tachycardia (VT) is mostly found in patients with a structurally healthy heart. These PVC/VT usually have a focal origin. The most likely mechanism is delayed post-depolarization. Localization of the origin is based on the creation of an activation map with or without combination of pace mapping. Idiopathic PVC/VT are most frequently located on the outflow tracts of the right and left ventricles, including the aortic root. Other typical locations include the annulus of the tricuspid or mitral valve, papillary muscles and Purkinje fibers. Catheter ablation is an alternative to antiarrhythmic medication in symptomatic monomorphic PVC/VT. The success rate is good whereby mapping and ablation can often represent a challenge. This article is the fifth part of a series dedicated to specific advanced training in the field of special rhythmology and invasive electrophysiology. It describes the pathophysiological principles, types and typical findings that can be obtained during an electrophysiological investigation.
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Affiliation(s)
- Sonia Busch
- II. Med. Klinik, Klinik für Kardiologie, Angiologie, Pneumologie, Klinikum Coburg, Ketschendorfer Str. 33, 96450, Coburg, Deutschland.
| | - Lars Eckardt
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Philipp Sommer
- Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Deutschland
| | - Christian Meyer
- Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie, Universitäres Herzzentrum Hamburg, Hamburg, Deutschland
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Dierk Thomas
- Department of Cardiology, Medical University Hospital, Heidelberg, Deutschland
- HCR (Heidelberg Center for Heart Rhythm Disorders), Heidelberg, Deutschland
- partner site Heidelberg/Mannheim, DZHK (German Center for Cardiovascular Research), Heidelberg, Deutschland
| | | | - Roland Richard Tilz
- Medizinische Klinik II (Kardiologie, Angiologie, Intensivmedizin) - Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein (UKSH), Lübeck, Deutschland
| | - Daniel Steven
- Herzzentrum, Abteilung für Elektrophysiologie, Uniklinik Köln, Köln, Deutschland
| | - Christian von Bary
- Medizinische Klinik I, Rotkreuzklinikum München - Akademisches Lehrkrankenhaus der Technischen Universität München, München, Deutschland
| | - Malte Kuniss
- Abteilung für Kardiologie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
| | - Frederic Voss
- Innere Medizin 3, Krankenhaus der Barmherzigen Brüder Trier, Trier, Deutschland
| | - Heidi L Estner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München (LMU München), München, Deutschland
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8
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The autonomic neural mechanism of right ventricular outflow tract tachycardia. Auton Neurosci 2018; 212:10-16. [DOI: 10.1016/j.autneu.2018.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/18/2018] [Accepted: 03/27/2018] [Indexed: 11/30/2022]
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9
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Conventional mapping and ablation of focal ventricular tachycardias in the healthy heart. Herzschrittmacherther Elektrophysiol 2017; 28:187-192. [PMID: 28484842 DOI: 10.1007/s00399-017-0505-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Abstract
Ventricular tachycardias (VT) in the healthy heart, also known as idiopathic VTs, often have a focal origin. Triggered activity due to delayed after-depolarization is the most likely mechanism of focal VTs. Localization of the site of origin of focal VTs is based on activation mapping with or without combination with pace mapping. The characteristic anatomic site of origin of idiopathic VTs is the right and left outflow tract. Other sites include the tricuspid and mitral annulus, the papillary muscles, and Purkinje fibers. Catheter ablation is indicated for monomorphic symptomatic VT and can be an alternative to antiarrhythmic drugs. Success rates are high, but mapping and ablation can be challenging. We review the main electrophysiological findings and the important clues for ablation of focal VTs. Specific considerations for each location are considered.
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10
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Wang Z, Gao H, Dong R, Zhao C, Yu T, Yang L, Peng H, Wu Y. Increased Local Sympathetic Nerve Activity During Pathogenesis of Ventricular Arrhythmias Originating from the Right Ventricular Outflow Tract. Med Sci Monit 2017; 23:1090-1098. [PMID: 28248919 PMCID: PMC5344280 DOI: 10.12659/msm.900143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The contribution of local sympathetic nerves to ventricular arrhythmia (VA) originating from the right ventricular outflow tract (RVOT) has not been elucidated. This study used a canine model to investigate the anatomical changes of the RVOT associated with VA, and the distribution of local sympathetic nerves. Material/Methods The RVOT-VA canine model (6 dogs) was induced with a circular catheter and high-frequency stimulation (100 Hz) in the middle of the pulmonary artery trunk. Six dogs who were not given stimulation served as the control group. The serum levels of neurotransmitters, the extent of myocardial extension, and the sympathetic nerve density of the RVOT were also analyzed. Results Ventricular arrhythmias, including premature ventricular contractions, were induced in the experimental group after high-frequency stimulation. Dogs from the RVOT-VA group showed enhanced myocardial extension and sympathetic nerve density in the septal wall as compared with those of the free wall of the RVOT. In the RVOT-VA dogs, serum norepinephrine and neuropeptide Y and the sympathetic nerve density were significantly higher compared with the control group. Conclusions Stimulation of the pulmonary artery could activate local sympathetic nerves and enhance myocardial extension, which may be the foundation of RVOT-VA. The RVOT voltage transitional zone positively correlated with myocardial extension, which may serve as an important target for the radiofrequency catheter ablation of RVOT-VA clinically.
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Affiliation(s)
- Zefeng Wang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Huikuan Gao
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Ruiqing Dong
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Can Zhao
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Tianyu Yu
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Lu Yang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Hui Peng
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yongquan Wu
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
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11
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Michowitz Y, Viskin S, Rosso R. Exercise-induced Ventricular Tachycardia/Ventricular Fibrillation in the Normal Heart: Risk Stratification and Management. Card Electrophysiol Clin 2016; 8:593-600. [PMID: 27521092 DOI: 10.1016/j.ccep.2016.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Exercise-induced ventricular tachycardia (VT) rarely occurs in the absence of organic heart disease. Idiopathic monomorphic VT has an excellent prognosis. The main aspect of the risk stratification process is recognizing subtle forms of organic heart disease, particularly arrhythmogenic right ventricular cardiomyopathy. Exercise-induced polymorphic VT is potentially malignant. Exercise-induced polymorphic VT has also been seen in mitral valve prolapse. Some patients with stable coronary disease, and even healthy athletes, sometimes have short bursts of polymorphic VT during exercise tests but these arrhythmias are usually not reproducible during repeated testing and have unknown long-term clinical significance.
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Affiliation(s)
- Yoav Michowitz
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Weizman 6, Tel Aviv 64239, Israel
| | - Sami Viskin
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Weizman 6, Tel Aviv 64239, Israel.
| | - Raphael Rosso
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Weizman 6, Tel Aviv 64239, Israel
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12
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Wang Y, Patel D, Wang DW, Yan JT, Hsia HH, Liu H, Zhao CX, Zuo HJ, Wang DW. β1-Adrenoceptor blocker aggravated ventricular arrhythmia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:1348-56. [PMID: 23750689 DOI: 10.1111/pace.12196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 04/11/2013] [Accepted: 04/18/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the impact of β1 -adrenoceptor blockers (β1 -blocker) and isoprenaline on the incidence of idiopathic repetitive ventricular arrhythmia that apparently decreases with preprocedural anxiety. METHODS From January 2010 to July 2012, six patients were identified who had idiopathic ventricular arrhythmias that apparently decreased (by greater than 90%) with preprocedural anxiety. The number of ectopic ventricular beats per hour (VPH) was calculated from Holter or telemetry monitoring to assess the ectopic burden. The mean VPH of 24 hours from Holter before admission (VPH-m) was used as baseline (100%) for normalization. β1 -Blockers, isoprenaline, and/or aminophylline were administrated successively on the ward and catheter lab to evaluate their effects on the ventricular arrhythmias. RESULTS Among 97 consecutive patients with idiopathic ventricular arrhythmias, six had reduction in normalized VPHs in the hour before the scheduled procedure time from (104.6 ± 4.6%) to (2.8 ± 1.6%) possibly due to preprocedural anxiety (P < 0.05), then increased to (97.9 ± 9.7%) during β1 -blocker administration (P < 0.05), then quickly reduced to (1.6 ± 1.0%) during subsequent isoprenaline infusion. Repeated β1 -blocker quickly counteracted the inhibitory effect of isoprenaline, and VPHs increased to (120.9 ± 2.4%) from (1.6 ± 1.0%; P < 0.05). Isoprenaline and β1 -blocker showed similar effects on the arrhythmias in catheter lab. CONCLUSIONS In some patients with structurally normal heart and ventricular arrhythmias there is a marked reduction of arrhythmias associated with preprocedural anxiety. These patients exhibit a reproducible sequence of β1 -blocker aggravation and catecholamine inhibition of ventricular arrhythmias, including both repetitive ventricular premature beats and monomorphic ventricular tachycardia.
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Affiliation(s)
- Yan Wang
- Cardivascular Division, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
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Valk SDA, de Groot NMS, Szili-Torok T, Van Belle YLE, Res JCJ, Jordaens L. Clinical characteristics and acute results of catheter ablation for outflow tract ventricular tachycardia or premature beats. J Interv Card Electrophysiol 2012; 35:301-9; discussion 309. [PMID: 22869387 DOI: 10.1007/s10840-012-9706-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 06/06/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Contemporary outcome data of catheter ablation for outflow tract tachycardia (OTT) and ventricular premature beats (VPBs) are rare. The aim of this study was to describe the clinical characteristics, the acute procedure success rate, and the long-term survival of patients who underwent an ablation procedure for OTT or VPBs. METHODS The study was a single-center retrospective cohort study. All 82 consecutive OTT and VPB first ablation procedures between 1999 and 2009 were included. Patients with structural heart disease were excluded. RESULTS Mean age was 46 ± 13 years. Forty-three percent of the patients were male. All patients were alive after a median follow-up duration of 31 months (interquartile range, 14-65 months). Eighty-nine percent suffered from palpitations and 12 % had a history of syncope. Ventricular tachycardia was documented in 73 % and monomorphic VPBs in 99 %. Seventy-three percent of the patients were ablated in the right ventricular outflow tract, 15 % in the left ventricular outflow tract, and 12 % in the coronary cusps. Radiofrequency energy was used in 95 % of the patients, cryo energy in 9 %. Acute success was achieved in 78 %. Six patients (7 %) experienced a complication (five pericardial effusions, one pseudo-aneurysm of the femoral artery). Three patients needed pericardiocentesis (4 %). CONCLUSION Ablation for OTT and VPB is successful in the vast majority of cases, with a low but still existing complication rate. Long-term survival was excellent, underscoring the benign nature of this arrhythmia.
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Affiliation(s)
- Suzanne D A Valk
- Department of Clinical Electrophysiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Roberts-Thomson KC, Lau DH, Sanders P. The diagnosis and management of ventricular arrhythmias. Nat Rev Cardiol 2011; 8:311-21. [DOI: 10.1038/nrcardio.2011.15] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Bottoni N, Quartieri F, Lolli G, Iori M, Manari A, Menozzi C. Sudden death in a patient with idiopathic right ventricular outflow tract arrhythmia. J Cardiovasc Med (Hagerstown) 2009; 10:801-3. [DOI: 10.2459/jcm.0b013e32832cebbb] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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HASDEMIR CAN, ALP ALPAY, AYDIN MEHMET, CAN LEVENTH. Human Model Simulating Right Ventricular Outflow Tract Tachycardia by High-Frequency Stimulation in the Left Pulmonary Artery: Autonomics and Idiopathic Ventricular Arrhythmias. J Cardiovasc Electrophysiol 2009; 20:759-63. [DOI: 10.1111/j.1540-8167.2009.01442.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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ULUCAN CEM, CETINTAS VILDAN, TETIK ASLI, EROGLU ZUHAL, KAYIKCIOGLU MERAL, CAN LEVENTH, PAYZIN SERDAR, AYDIN MEHMET, HASDEMIR CAN. β1and β2-Adrenergic Receptor Polymorphisms and Idiopathic Ventricular Arrhythmias. J Cardiovasc Electrophysiol 2008; 19:1053-8. [DOI: 10.1111/j.1540-8167.2008.01202.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Morin DP, Lerman BB. Management of ventricular tachycardia in the absence of structural heart disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2008; 9:356-63. [PMID: 17897564 DOI: 10.1007/s11936-007-0055-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Ventricular tachycardia most often arises from the ventricular outflow tracts in patients with apparently structurally normal hearts, and is often termed idiopathic ventricular tachycardia. These tachycardias are characterized by a left bundle branch block, inferior axis QRS morphology, and a unique electropharmacologic profile. The choice of treatment is dictated by the severity of symptoms, and ranges from observation for asymptomatic patients, to antiarrhythmic agents for those who are mildly to moderately symptomatic (eg, palpitations), to catheter-based ablation for those with more troubling symptoms or those who develop tachycardia-mediated cardiomyopathy. Antiarrhythmic therapy can be effective for arrhythmia suppression, and radiofrequency ablation has a high success rate (> 90%) with few procedural complications. In general, ventricular outflow tract tachycardia has a favorable prognosis. Exclusion of arrhythmogenic right ventricular dysplasia/cardiomyopathy is important due to significant disparities in prognosis and treatment.
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Affiliation(s)
- Daniel P Morin
- Division of Cardiology, Cornell University Medical Center, 525 East 68th Street, Starr-4, New York, NY 10021, USA
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Uemura T, Yamabe H, Tanaka Y, Morihisa K, Kawano H, Kaikita K, Sumida H, Sugiyama S, Ogawa H. Catheter ablation of a polymorphic ventricular tachycardia inducing monofocal premature ventricular complex. Intern Med 2008; 47:1799-802. [PMID: 18854632 DOI: 10.2169/internalmedicine.47.1211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Ventricular tachycardia originating from the right ventricular outflow tract (RVOT) is considered benign, but sometimes it causes polymorphic ventricular tachycardia and ventricular fibrillation, resulting in sudden cardiac death. A 58-year-old woman without structural heart disease was admitted for evaluation of recurrent episodes of syncope. Surface ECG showed frequent repetitive premature ventricular contraction (PVC) of RVOT origin. Polymorphic ventricular tachycardia triggered by the same PVC was documented by Holter ECG during an episode of syncope. Radiofrequency catheter ablation was performed to eradicate this PVC. No polymorphic ventricular tachycardia has developed after the procedure, and the patient has had no recurrence of syncope.
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Affiliation(s)
- Takashi Uemura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto
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Abstract
Idiopathic ventricular tachycardia (VT) is an uncommon form of VT that is seen in patients without structural heart disease. It is commonly seen in young patients and usually has a benign course. Recent studies have delineated the mechanisms and anatomical locations of this form of VT. Recognition of various forms of idiopathic VT based on characteristic QRS morphology from the 12-lead electrocardiogram (ECG) has important prognostic and therapeutic implications. The understanding of the mechanisms of idiopathic VT has led to the use of specific antiarrhythmic drugs targeting particular arrhythmias. Recent technological advances in the field of mapping and catheter ablation have led to a suitable alternative to drug therapy with a very high cure rate. This review describes the clinical features, ECG recognition, and management of idiopathic monomorphic VT.
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Guías de Práctica Clínica del ACC/AHA/ESC 2006 sobre el manejo de pacientes con arritmias ventriculares y la prevención de la muerte cardiaca súbita.Versión resumida. Rev Esp Cardiol 2006. [DOI: 10.1157/13096582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Pellizzón OA, Beloscar JS, Mariani E. Adrenergic nervous system influences on the induction of ventricular tachycardia. Ann Noninvasive Electrocardiol 2006; 7:281-8. [PMID: 12431305 PMCID: PMC7027628 DOI: 10.1111/j.1542-474x.2002.tb00176.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Sudden cardiac death is a major cause of mortality in western countries and the ventricular tachyarrhythmias are mainly involved in this regard. The adrenergic autonomic nervous system has influences in provoking life-threatening arrhythmias, and the prevention of such arrhythmias with beta-blockers supports this viewpoint. To evaluate the effect of the adrenergic nervous system and some catecholamine-releasing stimuli on the induction of ventricular tachycardia, we decided to explore the occurrence of ventricular tachycardia in patients subjected to three consecutive tests, exercise testing, isoproterenol infusion, and mental stress. METHODS Nineteen subjects who experienced exercise test-induced ventricular tachycardia were subjected to an isoproterenol infusion and mental stress. All but one patient had cardiac disease, with 70% due to Chagas' disease. Seventeen of the 19 study subjects had normal ventricular function. RESULTS Exercise test-induced ventricular tachycardia was nonsustained in 17 patients and sustained in 2 cases. Isoproterenol infusion induced nonsustained ventricular tachycardia in 9 of 19 patients. Mental stress, on its own, was able to induce nonsustained ventricular tachycardia in 2 of 19 patients. CONCLUSIONS Among patients preselected for exercise-induced ventricular tachycardia, almost half could be induced into ventricular tachycardia by isoproterenol infusion. Mental stress was a less powerful inducer of ventricular arrhythmias in this study group.
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Affiliation(s)
- Oscar A Pellizzón
- Arrhythmia Section, Cardiology Department, School of Medicine, National University of Rosario, Ocampo 1969, (2000) Rosario, Santa Fe 3100, Argentina.
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Bunch TJ, Day JD. Right Meets Left: A Common Mechanism Underlying Right and Left Ventricular Outflow Tract Tachycardias. J Cardiovasc Electrophysiol 2006; 17:1059-61. [PMID: 16989647 DOI: 10.1111/j.1540-8167.2006.00577.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 863] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death—Executive Summary. Circulation 2006. [DOI: 10.1161/circulationaha.106.178104] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Myerburg RJ, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Moss AJ, Priori SG, Antman EM, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death—Executive Summary. J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.07.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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28
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e385-484. [PMID: 16935995 DOI: 10.1161/circulationaha.106.178233] [Citation(s) in RCA: 807] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Brembilla-Perrot B, Beurrier D, Houriez P, Claudon O, Rizk J, Lemoine C, Gregoire P, Nippert M. Transitory or permanent regular wide QRS complex tachycardia induced by atrial stimulation in patients without apparent heart disease. Significance. Ann Cardiol Angeiol (Paris) 2003; 52:226-31. [PMID: 14603703 DOI: 10.1016/s0003-3928(03)00090-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVES The purpose of the study was to evaluate the frequency of transitory or permanent bundle branch block (BBB) associated with a paroxysmal tachycardia induced by atrial stimulation in patients without heart disease and its significance. METHODS Esophageal atrial stimulation was performed in 447 patients suspected to have supraventricular tachycardias (SVT). Sustained regular tachycardia was induced in all of them but three, either in control state (75%) or after administering isoproterenol. In 346 patients, only narrow complex SVTs were induced (77%); in 259 of them, the reentry occurred in the AV node and in remaining patients within a concealed accessory pathway. In 62 patients, a transitory functional BBB was recorded at the onset of the tachycardia (14%). In 33 of them, the reentry occurred in the AV node and in the remaining 29 patients within a concealed accessory pathway. In 36 patients (8%), a permanently wide QRS complex tachycardia was induced. Three patients had also inducible narrow complex SVT. Atrial pacing induced a BBB similar to the aberrancy in tachycardia in 22 patients: the reentry occurred in the AV node in 17 patients, within a concealed accessory pathway in three patients and in a Mahaim bundle in two patients. In other patients, QRS complex remained normal during atrial pacing: all 14 patients had a ventricular tachycardia (VT), either a verapamil-sensitive VT (n = 7) or catecholamine-sensitive VT (n = 4) or bundle branch reentry (n = 3). Followed from 2 to 12 years, the prognosis of these patients was excellent. CONCLUSION Transitory BBB at the onset of an SVT is noted in 14% of the population, is more frequent in patients with accessory pathway reentrant tachycardia, but is helpful for this diagnosis in only 12% of cases. A regular tachycardia with permanent left or right bundle branch morphology induced by atrial stimulation in a patient without heart disease and without BBB during atrial pacing is due to a VT even if this patient has also narrow complex tachycardias. This mechanism does not affect the excellent prognosis of this population.
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Ouyang F, Antz M, Deger FT, Bänsch D, Schaumann A, Ernst S, Kuck KH. An underrecognized subepicardial reentrant ventricular tachycardia attributable to left ventricular aneurysm in patients with normal coronary arteriograms. Circulation 2003; 107:2702-9. [PMID: 12743007 DOI: 10.1161/01.cir.0000068343.69532.b6] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with apparently normal hearts, ventricular tachycardia (VT) may only involve the subepicardial myocardium. METHODS AND RESULTS Four patients with exercise-induced fast VT with right bundle branch block morphology were investigated. ECG showed a small q wave in leads II, III, and aVF during sinus rhythm (SR) in all 4 patients. Left ventricular angiography showed small inferolateral aneurysms in all patients. Coronary arteriograms were normal in all 4 patients. Six unstable VTs (cycle length, 200 to 305 ms) and 1 stable VT (cycle length 370 ms) were reproducibly induced in the 4 patients. During SR, endocardial mapping was normal in all 4 patients, and epicardial mapping showed fragmented and late potentials in the left inferolateral wall anatomically consistent with the left ventricle aneurysm. During tachycardia, epicardial mapping showed a macroreentrant VT with focal endocardial activation in the patient with stable VT, whereas in 2 patients with unstable VT, a diastolic potential was only recorded and coincided with the late potential in the same area. Epicardial ablation was performed in 3 patients and successfully abolished those VTs. No VT recurred in 2 patients during follow-up of 2 and 9 months. Clinical VT recurred 6 months after the ablation and was successfully ablated in a repeated epicardial ablation in 1 patient. In the remaining patient without epicardial ablation, an implantable cardiac defibrillator was implanted. There were multiple shocks during a follow-up of 31 months. CONCLUSIONS In patients with normal coronary arteriograms and left ventricle aneurysm, exercise-induced VT with right bundle branch block morphology may have a subepicardial arrhythmogenic substrate, which may be amenable to epicardial ablation.
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Affiliation(s)
- Feifan Ouyang
- II. Med. Abteilung, Allgemeines Krankenhaus St Georg, Lohmühlenstr. 5, 20099 Hamburg, Germany.
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Krittayaphong R, Bhuripanyo K, Punlee K, Kangkagate C, Chaithiraphan S. Effect of atenolol on symptomatic ventricular arrhythmia without structural heart disease: a randomized placebo-controlled study. Am Heart J 2002; 144:e10. [PMID: 12486439 DOI: 10.1067/mhj.2002.125516] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ventricular arrhythmia (VA) from the right ventricular outflow tract (RVOT) is a common problem. Symptomatic patients are usually treated with beta-blockers. There is little data on the systematic evaluation of the efficacy of beta-blocker. We determine the efficacy of atenolol in the treatment of symtomatic VA from RVOT compared with placebo. METHODS AND RESULTS This was a randomized, double-blinded, placebo-controlled study. We prospectively studied 52 consecutive patients with symptomatic VA. Severity of symptoms, 24-hour ambulatory monitoring (AECG) and quality of life (QOL) were assessed at baseline and 1 month after atenolol. Exercise testing was performed at baseline. Average premature ventricular complex (PVC) count at baseline was 21,407 +/- 1740 beats per 24 hours, and 19% had ventricular tachycardia as measured by AECG. Results of this study showed that atenolol significantly decreased symptom frequency (P =.03), PVC count (P =.001) and average heart rate (P <.001) measured by AECG, whereas placebo significantly decreased symptom frequency (P =.002) but had no effect on PVC count (P =.78) or average heart rate (P =.44). Neither atenolol nor placebo had an effect on QOL. CONCLUSIONS Atenolol improves symptoms and decreases PVC count from ambulatory monitoring. Placebo improved symptoms to the same extent as atenolol but had no effect on severity of VA. This might be the so-called placebo effect, which is a concern when treating patients or doing research on the effects of a drug.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Safi AM, Chaudhry K, Stein RA. Multi-morphology wide QRS tachycardias in a patient without structural heart disease: an unusual presentation of ventricular tachycardia. JAPANESE HEART JOURNAL 2001; 42:633-8. [PMID: 11804305 DOI: 10.1536/jhj.42.633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Ventricular tachycardia occurs infrequently in patients without structural heart disease. These tachycardias commonly originate from the right ventricular outflow tract. However, the presence of more than one arrhythmogenic substrate in a patient without structural heart disease is rare. We report such a 48-year old patient with no structural heart disease who presented with three morphology wide QRS tachycardia. A brief review of the pathophysiology and management is discussed.
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Affiliation(s)
- A M Safi
- Department of Medicine, The Brooklyn Hospital Center, New York 11201, USA
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Phillips JR, Case CL. Mapping and ablation of ventricular tachycardia in children and adolescents. PROGRESS IN PEDIATRIC CARDIOLOGY 2001; 13:53-60. [PMID: 11413058 DOI: 10.1016/s1058-9813(01)00083-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Ventricular tachycardia is a rare arrhythmia in the pediatric population that occurs in structurally normal and abnormal hearts. The treatment of ventricular tachycardia is aimed at reducing symptoms and the risk of sudden death. The intracardiac electrophysiology study and radiofrequency ablation have come to the forefront of diagnostic and therapeutic options for patients with ventricular arrhythmias. The indications for radiofrequency ablation are debated, but it has been shown to be an effective and safe means of eliminating ventricular tachycardia. The purpose of this review is to outline the mechanisms and electrophysiologic characteristics of ventricular tachycardia, discuss the forms common to the pediatric population and summarize the indications, success and complications of radiofrequency ablation for ventricular tachycardia.
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Affiliation(s)
- J R. Phillips
- Division of Pediatric Cardiology, Cook Children's Heart Center, 901 Seventh Avenue, Suite 310, 76104-2734, Fort Worth, TX, USA
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Dixit S, Marchlinski FE. Clinical characteristics and catheter ablation of left ventricular outflow tract tachycardia. Curr Cardiol Rep 2001; 3:305-13. [PMID: 11406089 DOI: 10.1007/s11886-001-0085-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Left ventricular outflow tract (LVOT) tachycardia is an uncommon form of idiopathic ventricular tachycardia (IVT). The underlying mechanism of this arrhythmia appears to be cyclic AMP-medicated triggered activity. The tachycardia occurs in the absence of structural heart disease and is generally benign, presenting commonly as palpitations and presyncope. It can manifest either a right or left bundle branch block morphology with an inferior axis. Subtle variations in the QRS morphology in leads I, V1, and V2 can help in localizing the anatomic site of origin (SOO). The arrhythmia is typically responsive to a variety of pharmacologic agents (beta-blockers, calcium channel blockers, Class I and II agents). Radiofrequency catheter ablation of LVOT tachycardia SOO as determined by pace mapping is quite efficacious (success rates of 90%). Magnetic electroanatomic mapping augments this by permitting three-dimensional catheter mapping and reproducible localization of the SOO. Catheter ablation should be considered relatively early in patients who experience severe symptoms with their arrhythmia and have failed, or are reluctant to take medications for the disorder.
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Affiliation(s)
- S Dixit
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Founders, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
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Abstract
Idiopathic ventricular tachycardia (VT) is characterized by two predominant forms. The most common form originates from the right ventricular outflow tract and presents as repetitive monomorphic VT or exercise-induced VT. The tachycardia is adenosine sensitive and is thought to be because of cAMP-mediated triggered activity. The other major form of idiopathic VT is owing to verapamil-sensitive intrafascicular re-entrant tachycardia, which most often originates in the region of the left posterior fascicle. Both forms of idiopathic VT can be readily treated with radiofrequency catheter ablation.
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Affiliation(s)
- B B Lerman
- Department of Medicine, New York Hospital-Cornell University Medical Center, New York, USA.
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Abstract
Most ventricular tachycardias encountered in clinical practice occur in patients who have structural heart disease. Idiopathic ventricular tachycardia refers to those arrhythmias that occur in patients without structural heart disease, metabolic/electrolyte abnormalities, or the long QT syndrome. Three commonly recognized forms of idiopathic ventricular tachycardia include: (a) ventricular tachycardia associated with mitral valve prolapse, (b) ventricular tachycardia originating from the right ventricular outflow tract, and (c) ventricular tachycardia originating from the left ventricle. Recently, a fourth type of idiopathic ventricular tachycardia, termed the Brugada syndrome, has been identified as responsible for some cases of cardiac arrest in persons without apparent structural heart disease. Each form of ventricular tachycardia may be considered a discrete syndrome based on its electrocardiographic characteristics, mechanisms, responses to pharmacologic intervention, and prognosis (good in most cases). Ventricular tachycardias range from the common to the exotic, but all represent syndromes with which the internist and general cardiologist should be familiar.
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Affiliation(s)
- G T Altemose
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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Gill JS, Prasad K, Blaszyk K, Ward DE, Camm AJ. Initiating sequences in exercise induced idiopathic ventricular tachycardia of left bundle branch-like morphology. Pacing Clin Electrophysiol 1998; 21:1873-80. [PMID: 9793082 DOI: 10.1111/j.1540-8159.1998.tb00005.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Initiating sequences for VT may infer the underlying arrhythmogenic mechanisms. This study examines the initiating sequences of exercise induced idiopathic VT of left bundle branch block-like (LBBB-like) morphology and makes an attempt to relate these to clinical aspects and the mechanisms of arrhythmia. Thirty-two patients (mean age 33.4 +/- 13.2 years; 18 men) with exercise induced VT in the absence of structural cardiac abnormality on history, clinical examination, and noninvasive and invasive investigations were divided into two groups on the basis of the initiating sequence of VT on exercise. Group I consisted of patients with long-short sequence of RR intervals prior to the onset of VT (initiating/preinitiating cycle length ratio < or = 0.78). Group II consisted of patients without changes in cycle length prior to VT. Group I mechanism would suggest delayed afterdepolarizations (DADs) or reentry whereas group II mechanism triggered activity due to early afterdepolarizations. Fourteen patients (group I) had long-short sequence and 18 patients (group II) were without cycle length changes prior to VT initiated during exercise. VT axis was inferior in all 18 patients in group II but only in 9 patients in group I (P = 0.02). In these predefined patient groups, sustained monomorphic VT could not be initiated by programmed stimulation in any patient in group I, whereas four patients in group II had inducible VT. Patients in group II also had higher incidence of sustained VT on ambulatory monitoring (P < 0.05). The two groups did not differ in other respects. This study demonstrates the existence of at least two possible mechanisms of initiation of exercise induced idiopathic VT of LBBB-like morphology. VT initiated without cycle length changes is more common, more likely to have an inferior axis suggesting an outflow tract origin, and is probably related to triggered activity secondary to DADs. VT initiated with a long-short sequence is more often nonsustained and may have a superior axis suggesting an origin from the body or septal region of the ventricle. The two groups, therefore, exhibit differences in electrophysiological characteristics that may aid classification and therapy of this arrhythmia.
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Affiliation(s)
- J S Gill
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, United Kingdom
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Tsai CF, Chen SA, Tai CT, Chiang CE, Lee SH, Wen ZC, Huang JL, Ding YA, Chang MS. Idiopathic monomorphic ventricular tachycardia: clinical outcome, electrophysiologic characteristics and long-term results of catheter ablation. Int J Cardiol 1997; 62:143-50. [PMID: 9431865 DOI: 10.1016/s0167-5273(97)00198-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Ventricular tachycardia (VT) without structural heart disease or any identifiable predisposing causes for arrhythmia is an uncommon but well-recognized clinical entity. The purpose of this study is to assess the results of catheter ablation therapy and the long-term outcome of patients with idiopathic monomorphic VT in a large patient group. Sixty-one consecutive patients (male/female=40/21; mean age 38+/-16 years) with idiopathic VT underwent electrophysiologic study and an attempt of catheter ablation therapy. The 'left VT' group included 31 patients with QRS morphology of right bundle branch block during VT suggestive of the VT originating from the left ventricle (LV), and the 'right VT' group consisted of 30 patients with QRS morphology of left bundle branch block with normal or right frontal axis deviation suggestive of VT arising from right ventricular outflow tract (RVOT). Idiopathic left VT has sustained VT during the clinical attacks, baseline electrophysiologic study or after isoproterenol infusion; it can be entrained by overdrive ventricular pacing, terminated by verapamil, but not by adenosine (except one case with VT focus at left ventricular free wall). Catheter ablation was successful in 22 (84%) of 26 patients, with recurrence rate of 9%. The successful ablation sites were located at LV inferior-apical septum (16 patients), mid-septum (three patients), high septum (two patients) and high anterior wall (one patient). In the right VT group, 20 (67%) of 30 patients presented clinically repetitive monomorphic VT. Most of the idiopathic right VT (22/30) required isoproterenol to facilitate induction of VT, and were sensitive to both verapamil and adenosine. Successful catheter ablation was achieved in 21 (84%) of 25 patients, with recurrence rate 19%. The successful ablation sites were located at RVOT-septum in 18 patients, and RVOT-free wall in three patients. During a mean follow-up period of 29.2+/-21.7 months (range 1-76 months) after hospital discharge, all patients were alive but one left VT case died of non-cardiovascular cause. We concluded that idiopathic left side and right side VTs have their distinct clinical, electrophysiologic and electropharmacological characteristics suggestive of different underlying mechanisms, and both have a benign prognosis. Furthermore, catheter ablation can be effective in eliminating idiopathic VT originating from the right ventricular outflow tract and left ventricle.
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Affiliation(s)
- C F Tsai
- Department of Medicine, National Yang-Ming University, School of Medicine, and Veterans General Hospital-Taipei, Taiwan, ROC
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Abstract
Idiopathic ventricular tachycardias occur in "normal" hearts and are generally benign arrhythmias. They can arise from either the left or right ventricle, and the origin is usually predictable from the surface ECG. These arrhythmias are produced by diverse mechanisms. When treatment is indicated, empiric pharmacotherapy can be successful. However, if drugs are not tolerated or fail, radiofrequency (RF) ablation may be indicated. During electrophysiologic study, arrhythmia mechanism can be determined, and pace and activation mapping can be used to localize the site of ventricular tachycardia origin to direct application of RF lesions. RF ablative therapy has been associated with high success rates.
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Affiliation(s)
- N Varma
- Thorndike Institute of Electrophysiology, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts 02215, USA
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Lerman BB, Stein KM, Markowitz SM. Idiopathic right ventricular outflow tract tachycardia: a clinical approach. Pacing Clin Electrophysiol 1996; 19:2120-37. [PMID: 8994952 DOI: 10.1111/j.1540-8159.1996.tb03287.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Right ventricular outflow tract (RVOT) tachycardia is the most common form of idiopathic ventricular tachycardia (VT). Phenotypically, RVOT tachycardia segregates into two predominant forms, one characterized by repetitive monomorphic nonsustained VT and the other by paroxysmal exercise induced sustained VT. There is an increasing body of evidence to support the concept that both forms of tachycardia reflect disparate clinical manifestations of an identical cellular mechanism (i.e., cAMP-mediated triggered activity), which is identified clinically by the tachycardia's sensitivity to adenosine. The clinical characteristics, natural history, and approaches to therapy of RVOT tachycardia are delineated herein.
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Affiliation(s)
- B B Lerman
- Department of Medicine, New York Hospital-Cornell University Medical Center, NY 10021, USA.
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Brodsky MA, Orlov MV, Allen BJ, Orlov YS, Wolff L, Winters R. Clinical assessment of adrenergic tone and responsiveness to beta-blocker therapy in patients with symptomatic ventricular tachycardia and no apparent structural heart disease. Am Heart J 1996; 131:51-8. [PMID: 8554019 DOI: 10.1016/s0002-8703(96)90050-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To further define the relation between changing adrenergic tone, beta-blocker therapy, and clinical ventricular tachycardia (VT), we evaluated these factors in 35 patients with VT unrelated to coronary artery disease or ventricular dysfunction. Testing included Holter monitoring (91% had VT), exercise test (69% had VT), Adrenergic responsiveness of VT was graded according to diurnal variation, response to exercise, isoproterenol infusion, and response to beta-blockers. beta-Blockers were effective and well tolerated in this population. There was also a predictable relation between changing adrenergic tone and the arrhythmia response to beta-blocker therapy.
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Affiliation(s)
- M A Brodsky
- Department of Medicine, University of California Irvine Medical Center, Orange 92668-3298, USA
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Coumel P, Leenhardt A, Haddad G. Exercise ECG: prognostic implications of exercise induced arrhythmias. Pacing Clin Electrophysiol 1994; 17:417-27. [PMID: 7513869 DOI: 10.1111/j.1540-8159.1994.tb01408.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- P Coumel
- Hôpital Lariboisière, Paris, France
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Abstract
Important data have recently been added to our understanding of sustained ventricular tachyarrhythmias occurring in the absence of demonstrable heart disease. Idiopathic ventricular tachycardia (VT) is usually of monomorphic configuration and can be classified according to its site of origin as either right monomorphic (70% of all idiopathic VTs) or left monomorphic VT. Several physiopathological types of monomorphic VT can be presently individualized, according to their mode of presentation, their relationship to adrenergic stress, or their response to various drugs. The long-term prognosis is usually good. Idiopathic polymorphic VT is a much rarer type of arrhythmia with a less favorable prognosis. Idiopathic ventricular fibrillation may represent an underestimated cause of sudden cardiac death in ostensibly healty patients. A high incidence of inducibility of sustained polymorphic VT with programmed ventricular stimulation has been found by our group, but not by others. Long-term prognosis on Class IA antiarrhythmic medications that are highly effective at electrophysiologic study appears excellent.
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Affiliation(s)
- B Belhassen
- Department of Cardiology, Tel Aviv-Elias Sourasky Medical Center, Israel
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