Conferences (Committee to develop guidelines for the management of patients with atrial fibrillat... more Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology This document is available on the World Wide Web sites of the European Society of Cardiology (www.escardio.org), the American College of Cardiology (www.acc.org), the American Heart Association
Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance, increasing in p... more Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance, increasing in prevalence with age. AF is often associated with structural heart disease, although a substantial proportion of patients with AF have no detectable heart disease. Hemodynamic impairment and thromboembolic events related to AF result in significant morbidity, mortality, and cost. Accordingly, the American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) created a committee to establish guidelines for optimum management of this frequent and complex arrhythmia.
*Representative of the European Heart Rhythm Association (EHRA) †Representative of the American C... more *Representative of the European Heart Rhythm Association (EHRA) †Representative of the American College of Cardiology (ACC) ‡Representative of the Sociedade Brasileira de Arritmias Cardíacas (SOBRAC) xRepresentative of the American Heart Association (AHA) {Representative of the Latin American Heart Rhythm Society (LAHRS) #Representative of the Asia Pacific Heart Rhythm Society (APHRS) **Representative of the Japanese Heart Rhythm Society (JHRS) † †Representative of the Pediatric and Congenital Electrophysiology Society (PACES)
Writing committee members are required to recuse themselves from voting on sections to which thei... more Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. Section numbers pertain to those in the full-text guideline. † ACC/AHA Representative. ‡ HRS Representative.
Circulation: Arrhythmia and Electrophysiology, 2017
Background— When anatomic obstacles preclude radiofrequency catheter ablation of idiopathic ventr... more Background— When anatomic obstacles preclude radiofrequency catheter ablation of idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT), an alternative approach from the anatomically opposite side (endocardial versus epicardial or above versus below the aortic valve) may be considered (anatomic ablation). The purpose of this study was to investigate the efficacy of an anatomic ablation in idiopathic LVOT VAs. Methods and Results— We studied 229 consecutive patients with idiopathic LVOT VAs. Radiofrequency ablation from the first suitable site was successful in 190 patients, and in the remaining 39 patients, it was unsuccessful or had to be abandoned because of anatomic obstacles. In 22 of these 39 patients, an anatomic ablation was successful, and the VA origins were located in the intramural LVOT in 17 patients, basal left ventricular summit in 4, and LVOT septum near the His bundle in 1. The anatomic ablation was highly successful for i...
Circulation: Arrhythmia and Electrophysiology, 2016
Background— Radiofrequency catheter ablation (RFCA) of idiopathic ventricular arrhythmias (VAs) o... more Background— Radiofrequency catheter ablation (RFCA) of idiopathic ventricular arrhythmias (VAs) originating from the basal portion of the left ventricular (LV) summit, which is divided from the apical LV (A-LV) summit by the great cardiac vein (GCV), is challenging. This study investigated the efficacy of RFCA and electrocardiographic and electrophysiological characteristics of these VAs. Methods and Results— Forty-five consecutive patients with symptomatic idiopathic LV summit VAs were studied. RFCA was successful within the main trunk of the GCV in 16 patients and within a branch of the GCV traversing the basal LV (B-LV) summit in 7. Transpericardial RFCA was successful on the epicardial surface in the A-LV summit in 6 patients and was abandoned in 14 with the B-LV summit VAs because of the close proximity to the coronary arteries and thick fat pads. RFCA was successful at the aortomitral continuity in 3 patients (2 with a failed transpericardial RFCA), and left coronary cusp in 1...
Idiopathic ventricular arrhythmias (VAs) are ventricular tachycardias (VTs) or premature ventricu... more Idiopathic ventricular arrhythmias (VAs) are ventricular tachycardias (VTs) or premature ventricular contractions (PVCs) with a mechanism that is not related to myocardial scar. The sites of successful catheter ablation of idiopathic VA origins have been progressively elucidated and include both the endocardium and, less commonly, the epicardium. Idiopathic VAs usually originate from specific anatomical structures such as the ventricular outflow tracts, aortic root, atrioventricular (AV) annuli, papillary muscles, Purkinje network and so on, and exhibit characteristic electrocardiograms based on their anatomical background. Catheter ablation of idiopathic VAs is usually safe and highly successful, but can sometimes be challenging because of the anatomical obstacles such as the coronary arteries, epicardial fat pads, intramural and epicardial origins, AV conduction system and so on. Therefore, understanding the relevant anatomy is important to achieve a safe and successful catheter a...
Circulation. Arrhythmia and electrophysiology, 2016
Idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVO... more Idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT) sometimes require catheter ablation from both the endocardial and epicardial sides for their elimination, suggesting the presence of intramural VA foci. This study investigated the prevalence and electrocardiographic and electrophysiological characteristics of these idiopathic intramural LVOT VAs when compared with the idiopathic endocardial and epicardial LVOT VAs. We studied 82 consecutive VAs with origins in the aortomitral continuity (n=30), LV summit (n=34), and intramural site (n=18). The maximum deflection index (the time to the maximum deflection in the precordial leads/QRS duration) was the largest in LV summit VAs (0.52±0.07), smallest in aortomitral continuity VAs (0.45±0.06), and midrange in intramural VAs (0.49±0.05). The electrocardiographic and electrophysiological characteristics of the intramural LVOT VAs were similar to those of the aortomitral continuity VAs. The in...
This document addresses the indications for diagnostic testing, the present state of prognostic r... more This document addresses the indications for diagnostic testing, the present state of prognostic risk stratification, and the treatment strategies that have been demonstrated to improve the clinical outcome of patients with VAs. In addition, this document includes recommendations for referral of patients to centres with specialized expertise in the management of arrhythmias. Wherever appropriate, the reader is referred to other publications regarding the indications for implantable cardioverter-defibrillator (ICD) implantation, 1,2 catheter ablation, 3 inherited arrhythmia syndromes, 4,4a,5 congenital heart disease (CHD), 6 the use of amiodarone, 7 and the management of patient with ICD shocks, 8 syncope, 9 or those nearing end of life. 10 The consensus recommendations in this document use the standard Class I, IIa, IIb, and III classification 11 and the corresponding language: 'is recommended' for Class I consensus recommendation; 'can be useful' for a Class IIa consensus recommendation; 'may be considered' to signify a Class IIb consensus recommendation; 'should not' or 'is not recommended' for a Class III consensus recommendation (failure to provide any additional benefit and/or may be harmful). The level of evidence supporting these recommendations is defined as 'A', 'B', or 'C' depending on the number of populations studied, whether data are derived from randomized clinical trials, non-randomized
Journal of the American College of Cardiology, 2007
The purpose of this study was to examine the relationship between the origin and breakout site of... more The purpose of this study was to examine the relationship between the origin and breakout site of idiopathic ventricular tachycardia (VT) or premature ventricular contractions (PVCs) originating from the myocardium around the ventricular outflow tract.
V2S/V3R Index Distinguishes LVOT from RVOT OriginsIntroductionAlthough several ECG criteria have ... more V2S/V3R Index Distinguishes LVOT from RVOT OriginsIntroductionAlthough several ECG criteria have been proposed for differentiating between left and right origins of idiopathic ventricular arrhythmias (VA) originating from the outflow tract (OT‐VA), their accuracy and usefulness remain limited. This study was undertaken to develop a more accurate and useful ECG criterion for differentiating between left and right OT‐VA origins.Methods and ResultsWe studied OT‐VAs with a left bundle branch block pattern and inferior axis QRS morphology in 207 patients who underwent successful catheter ablation in the right (RVOT; n = 154) or left ventricular outflow tract (LVOT; n = 53). The surface ECGs during the OT‐VAs and during sinus beats were analyzed with an electronic caliper. The V2S/V3R index was defined as the S‐wave amplitude in lead V2 divided by the R‐wave amplitude in lead V3 during the OT‐VA. The V2S/V3R index was significantly smaller for LVOT origins than RVOT origins (P < 0.001)...
Introduction: Focal ventricular arrhythmias (VAs) have been reported to arise from the posterior ... more Introduction: Focal ventricular arrhythmias (VAs) have been reported to arise from the posterior papillary muscle in the left ventricle (LV). We report a distinct subgroup of idiopathic VAs arising from the anterior papillary muscle (APM) in the LV. Methods and Results: We studied 432 consecutive patients undergoing catheter ablation for VAs based on a focal mechanism. Six patients were identified with ventricular tachycardia (VT, n = 1) or premature ventricular contractions (PVCs, n = 5) with the earliest site of ventricular activation localized to the base (n = 3) or middle portion (n = 3) of the LV APM. No Purkinje potentials were recorded at the ablation site during sinus rhythm or the VAs. All patients had a normal baseline electrocardiogram and normal LV systolic function. The VAs exhibited a right bundle branch block (RBBB) and right inferior axis (RIA) QRS morphology in all patients. Oral verapamil and/or Na+ channel blockers failed to control the VAs in 4 patients. VT was n...
BACKGROUND Idiopathic ventricular arrhythmias (VAs) can be rarely ablated from the noncoronary cu... more BACKGROUND Idiopathic ventricular arrhythmias (VAs) can be rarely ablated from the noncoronary cusp (NCC) of the aorta. OBJECTIVE The purpose of this study was to investigate the prevalence and the clinical, electrocardiographic, and electrophysiologic characteristics of idiopathic NCC VAs.
Idiopathic ventricular tachycardias (VTs) and premature ventricular contractions (PVCs) arising f... more Idiopathic ventricular tachycardias (VTs) and premature ventricular contractions (PVCs) arising from the tricuspid annulus have been reported. The purpose of this study was to clarify the prevalence and characteristics of VT/PVCs originating from the tricuspid annulus. The ECG characteristics and results of radiofrequency (RF) catheter ablation were analyzed in 454 patients with idiopathic VT/PVCs. Thirty-eight (8%) patients had VT/PVCs arising from the tricuspid annulus: 28 VT/PVCs (74%) originated from the septal portion of the tricuspid annulus and the remaining 10 (26%) from the free wall of the tricuspid annulus. QRS duration and Q-wave amplitude in each of leads V1-V3 were greater in VT/PVCs arising from the free wall of the tricuspid annulus than those from the septum of the tricuspid annulus (all P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .01). &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Notching&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; of the QRS complex was observed more often in VT/PVCs arising from the free wall of the tricuspid annulus than those from the septum of the tricuspid annulus (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .01). A Q wave in lead V1 was observed more often in VT/PVCs arising from the septum of the tricuspid annulus than those from the free wall of the tricuspid annulus (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .005). R-wave transition occurred beyond lead V3 more often in VT/PVCs arising from the free wall of the tricuspid annulus than those from the septum of the tricuspid annulus (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .005). RF catheter ablation eliminated 90% of the VT/PVCs arising from the free wall of the tricuspid annulus but only 57% of the VT/PVCs arising from septum of the tricuspid annulus. Idiopathic VT/PVCs arising from tricuspid annulus are not rare, and the detailed origin can be determined by ECG analysis. The preferential site of origin was the septum but also could be the free wall of the tricuspid annulus.
A 73-year-old man with idiopathic premature ventricular contractions (PVCs) underwent electrophys... more A 73-year-old man with idiopathic premature ventricular contractions (PVCs) underwent electrophysiological testing. Left ventricular activation mapping revealed a focal mechanism of the PVCs with the earliest activation on the anterior papillary muscle (APM). Irrigated radiofrequency (RF) current delivered at that site induced a cluster of non-sustained ventricular tachycardia episodes with the same QRS morphology as the PVCs, followed by ventricular fibrillation (VF). The APM might have served as an abnormal automatic trigger and driver for the VF occurrence. Ventricular fibrillation may occur as a complication during RF catheter ablation of papillary muscle ventricular arrhythmias even if the clinical arrhythmia is limited to PVCs.
We report the features of focal ventricular arrhythmias (VAs) arising from the left ventricle (LV... more We report the features of focal ventricular arrhythmias (VAs) arising from the left ventricle (LV) adjacent to the membranous septum. Methods and results We studied eight patients (five men, 65 + 10 years) with (n ¼ 2) or without structural heart disease (n ¼ 6) who had ventricular tachycardia (n ¼ 4) or premature ventricular contractions (n ¼ 4) originating from the LV septum underneath the aorta. Ventricular arrhythmias exhibited a focal activation pattern, left (n ¼ 4) or right bundle branch block (n ¼ 4), respectively, left superior (n ¼ 4) or inferior axis QRS morphology (n ¼ 4), negative QRS polarity in lead III and early or no precordial transition in all. During all of these VAs, far-field electrograms in the His bundle (HB) region preceded the QRS onset. In all patients, ventricular pre-potentials were recorded during VAs while late potentials were recorded in sinus rhythm at the border of a localized low-voltage area underneath the aorta. Radiofrequency catheter ablation at the presumed sites of origin successfully eliminated VAs in five patients and was abandoned in the remaining three because the HB electrogram was recorded at that site. Conclusion Focal VAs may arise from the LV adjacent to the membranous septum as a part of the LV ostium, and broadens the spectrum of LV ostium VAs.
*This document does not cover atrial fibrillation, which is covered in the ACC/AHA/ESC guidelines... more *This document does not cover atrial fibrillation, which is covered in the ACC/AHA/ESC guidelines on the management of patients with atrial fibrillation found on the ACC, AHA, and ESC Web sites.
Conferences (Committee to develop guidelines for the management of patients with atrial fibrillat... more Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology This document is available on the World Wide Web sites of the European Society of Cardiology (www.escardio.org), the American College of Cardiology (www.acc.org), the American Heart Association
Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance, increasing in p... more Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance, increasing in prevalence with age. AF is often associated with structural heart disease, although a substantial proportion of patients with AF have no detectable heart disease. Hemodynamic impairment and thromboembolic events related to AF result in significant morbidity, mortality, and cost. Accordingly, the American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) created a committee to establish guidelines for optimum management of this frequent and complex arrhythmia.
*Representative of the European Heart Rhythm Association (EHRA) †Representative of the American C... more *Representative of the European Heart Rhythm Association (EHRA) †Representative of the American College of Cardiology (ACC) ‡Representative of the Sociedade Brasileira de Arritmias Cardíacas (SOBRAC) xRepresentative of the American Heart Association (AHA) {Representative of the Latin American Heart Rhythm Society (LAHRS) #Representative of the Asia Pacific Heart Rhythm Society (APHRS) **Representative of the Japanese Heart Rhythm Society (JHRS) † †Representative of the Pediatric and Congenital Electrophysiology Society (PACES)
Writing committee members are required to recuse themselves from voting on sections to which thei... more Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. Section numbers pertain to those in the full-text guideline. † ACC/AHA Representative. ‡ HRS Representative.
Circulation: Arrhythmia and Electrophysiology, 2017
Background— When anatomic obstacles preclude radiofrequency catheter ablation of idiopathic ventr... more Background— When anatomic obstacles preclude radiofrequency catheter ablation of idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT), an alternative approach from the anatomically opposite side (endocardial versus epicardial or above versus below the aortic valve) may be considered (anatomic ablation). The purpose of this study was to investigate the efficacy of an anatomic ablation in idiopathic LVOT VAs. Methods and Results— We studied 229 consecutive patients with idiopathic LVOT VAs. Radiofrequency ablation from the first suitable site was successful in 190 patients, and in the remaining 39 patients, it was unsuccessful or had to be abandoned because of anatomic obstacles. In 22 of these 39 patients, an anatomic ablation was successful, and the VA origins were located in the intramural LVOT in 17 patients, basal left ventricular summit in 4, and LVOT septum near the His bundle in 1. The anatomic ablation was highly successful for i...
Circulation: Arrhythmia and Electrophysiology, 2016
Background— Radiofrequency catheter ablation (RFCA) of idiopathic ventricular arrhythmias (VAs) o... more Background— Radiofrequency catheter ablation (RFCA) of idiopathic ventricular arrhythmias (VAs) originating from the basal portion of the left ventricular (LV) summit, which is divided from the apical LV (A-LV) summit by the great cardiac vein (GCV), is challenging. This study investigated the efficacy of RFCA and electrocardiographic and electrophysiological characteristics of these VAs. Methods and Results— Forty-five consecutive patients with symptomatic idiopathic LV summit VAs were studied. RFCA was successful within the main trunk of the GCV in 16 patients and within a branch of the GCV traversing the basal LV (B-LV) summit in 7. Transpericardial RFCA was successful on the epicardial surface in the A-LV summit in 6 patients and was abandoned in 14 with the B-LV summit VAs because of the close proximity to the coronary arteries and thick fat pads. RFCA was successful at the aortomitral continuity in 3 patients (2 with a failed transpericardial RFCA), and left coronary cusp in 1...
Idiopathic ventricular arrhythmias (VAs) are ventricular tachycardias (VTs) or premature ventricu... more Idiopathic ventricular arrhythmias (VAs) are ventricular tachycardias (VTs) or premature ventricular contractions (PVCs) with a mechanism that is not related to myocardial scar. The sites of successful catheter ablation of idiopathic VA origins have been progressively elucidated and include both the endocardium and, less commonly, the epicardium. Idiopathic VAs usually originate from specific anatomical structures such as the ventricular outflow tracts, aortic root, atrioventricular (AV) annuli, papillary muscles, Purkinje network and so on, and exhibit characteristic electrocardiograms based on their anatomical background. Catheter ablation of idiopathic VAs is usually safe and highly successful, but can sometimes be challenging because of the anatomical obstacles such as the coronary arteries, epicardial fat pads, intramural and epicardial origins, AV conduction system and so on. Therefore, understanding the relevant anatomy is important to achieve a safe and successful catheter a...
Circulation. Arrhythmia and electrophysiology, 2016
Idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVO... more Idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT) sometimes require catheter ablation from both the endocardial and epicardial sides for their elimination, suggesting the presence of intramural VA foci. This study investigated the prevalence and electrocardiographic and electrophysiological characteristics of these idiopathic intramural LVOT VAs when compared with the idiopathic endocardial and epicardial LVOT VAs. We studied 82 consecutive VAs with origins in the aortomitral continuity (n=30), LV summit (n=34), and intramural site (n=18). The maximum deflection index (the time to the maximum deflection in the precordial leads/QRS duration) was the largest in LV summit VAs (0.52±0.07), smallest in aortomitral continuity VAs (0.45±0.06), and midrange in intramural VAs (0.49±0.05). The electrocardiographic and electrophysiological characteristics of the intramural LVOT VAs were similar to those of the aortomitral continuity VAs. The in...
This document addresses the indications for diagnostic testing, the present state of prognostic r... more This document addresses the indications for diagnostic testing, the present state of prognostic risk stratification, and the treatment strategies that have been demonstrated to improve the clinical outcome of patients with VAs. In addition, this document includes recommendations for referral of patients to centres with specialized expertise in the management of arrhythmias. Wherever appropriate, the reader is referred to other publications regarding the indications for implantable cardioverter-defibrillator (ICD) implantation, 1,2 catheter ablation, 3 inherited arrhythmia syndromes, 4,4a,5 congenital heart disease (CHD), 6 the use of amiodarone, 7 and the management of patient with ICD shocks, 8 syncope, 9 or those nearing end of life. 10 The consensus recommendations in this document use the standard Class I, IIa, IIb, and III classification 11 and the corresponding language: 'is recommended' for Class I consensus recommendation; 'can be useful' for a Class IIa consensus recommendation; 'may be considered' to signify a Class IIb consensus recommendation; 'should not' or 'is not recommended' for a Class III consensus recommendation (failure to provide any additional benefit and/or may be harmful). The level of evidence supporting these recommendations is defined as 'A', 'B', or 'C' depending on the number of populations studied, whether data are derived from randomized clinical trials, non-randomized
Journal of the American College of Cardiology, 2007
The purpose of this study was to examine the relationship between the origin and breakout site of... more The purpose of this study was to examine the relationship between the origin and breakout site of idiopathic ventricular tachycardia (VT) or premature ventricular contractions (PVCs) originating from the myocardium around the ventricular outflow tract.
V2S/V3R Index Distinguishes LVOT from RVOT OriginsIntroductionAlthough several ECG criteria have ... more V2S/V3R Index Distinguishes LVOT from RVOT OriginsIntroductionAlthough several ECG criteria have been proposed for differentiating between left and right origins of idiopathic ventricular arrhythmias (VA) originating from the outflow tract (OT‐VA), their accuracy and usefulness remain limited. This study was undertaken to develop a more accurate and useful ECG criterion for differentiating between left and right OT‐VA origins.Methods and ResultsWe studied OT‐VAs with a left bundle branch block pattern and inferior axis QRS morphology in 207 patients who underwent successful catheter ablation in the right (RVOT; n = 154) or left ventricular outflow tract (LVOT; n = 53). The surface ECGs during the OT‐VAs and during sinus beats were analyzed with an electronic caliper. The V2S/V3R index was defined as the S‐wave amplitude in lead V2 divided by the R‐wave amplitude in lead V3 during the OT‐VA. The V2S/V3R index was significantly smaller for LVOT origins than RVOT origins (P < 0.001)...
Introduction: Focal ventricular arrhythmias (VAs) have been reported to arise from the posterior ... more Introduction: Focal ventricular arrhythmias (VAs) have been reported to arise from the posterior papillary muscle in the left ventricle (LV). We report a distinct subgroup of idiopathic VAs arising from the anterior papillary muscle (APM) in the LV. Methods and Results: We studied 432 consecutive patients undergoing catheter ablation for VAs based on a focal mechanism. Six patients were identified with ventricular tachycardia (VT, n = 1) or premature ventricular contractions (PVCs, n = 5) with the earliest site of ventricular activation localized to the base (n = 3) or middle portion (n = 3) of the LV APM. No Purkinje potentials were recorded at the ablation site during sinus rhythm or the VAs. All patients had a normal baseline electrocardiogram and normal LV systolic function. The VAs exhibited a right bundle branch block (RBBB) and right inferior axis (RIA) QRS morphology in all patients. Oral verapamil and/or Na+ channel blockers failed to control the VAs in 4 patients. VT was n...
BACKGROUND Idiopathic ventricular arrhythmias (VAs) can be rarely ablated from the noncoronary cu... more BACKGROUND Idiopathic ventricular arrhythmias (VAs) can be rarely ablated from the noncoronary cusp (NCC) of the aorta. OBJECTIVE The purpose of this study was to investigate the prevalence and the clinical, electrocardiographic, and electrophysiologic characteristics of idiopathic NCC VAs.
Idiopathic ventricular tachycardias (VTs) and premature ventricular contractions (PVCs) arising f... more Idiopathic ventricular tachycardias (VTs) and premature ventricular contractions (PVCs) arising from the tricuspid annulus have been reported. The purpose of this study was to clarify the prevalence and characteristics of VT/PVCs originating from the tricuspid annulus. The ECG characteristics and results of radiofrequency (RF) catheter ablation were analyzed in 454 patients with idiopathic VT/PVCs. Thirty-eight (8%) patients had VT/PVCs arising from the tricuspid annulus: 28 VT/PVCs (74%) originated from the septal portion of the tricuspid annulus and the remaining 10 (26%) from the free wall of the tricuspid annulus. QRS duration and Q-wave amplitude in each of leads V1-V3 were greater in VT/PVCs arising from the free wall of the tricuspid annulus than those from the septum of the tricuspid annulus (all P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .01). &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Notching&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; of the QRS complex was observed more often in VT/PVCs arising from the free wall of the tricuspid annulus than those from the septum of the tricuspid annulus (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .01). A Q wave in lead V1 was observed more often in VT/PVCs arising from the septum of the tricuspid annulus than those from the free wall of the tricuspid annulus (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .005). R-wave transition occurred beyond lead V3 more often in VT/PVCs arising from the free wall of the tricuspid annulus than those from the septum of the tricuspid annulus (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .005). RF catheter ablation eliminated 90% of the VT/PVCs arising from the free wall of the tricuspid annulus but only 57% of the VT/PVCs arising from septum of the tricuspid annulus. Idiopathic VT/PVCs arising from tricuspid annulus are not rare, and the detailed origin can be determined by ECG analysis. The preferential site of origin was the septum but also could be the free wall of the tricuspid annulus.
A 73-year-old man with idiopathic premature ventricular contractions (PVCs) underwent electrophys... more A 73-year-old man with idiopathic premature ventricular contractions (PVCs) underwent electrophysiological testing. Left ventricular activation mapping revealed a focal mechanism of the PVCs with the earliest activation on the anterior papillary muscle (APM). Irrigated radiofrequency (RF) current delivered at that site induced a cluster of non-sustained ventricular tachycardia episodes with the same QRS morphology as the PVCs, followed by ventricular fibrillation (VF). The APM might have served as an abnormal automatic trigger and driver for the VF occurrence. Ventricular fibrillation may occur as a complication during RF catheter ablation of papillary muscle ventricular arrhythmias even if the clinical arrhythmia is limited to PVCs.
We report the features of focal ventricular arrhythmias (VAs) arising from the left ventricle (LV... more We report the features of focal ventricular arrhythmias (VAs) arising from the left ventricle (LV) adjacent to the membranous septum. Methods and results We studied eight patients (five men, 65 + 10 years) with (n ¼ 2) or without structural heart disease (n ¼ 6) who had ventricular tachycardia (n ¼ 4) or premature ventricular contractions (n ¼ 4) originating from the LV septum underneath the aorta. Ventricular arrhythmias exhibited a focal activation pattern, left (n ¼ 4) or right bundle branch block (n ¼ 4), respectively, left superior (n ¼ 4) or inferior axis QRS morphology (n ¼ 4), negative QRS polarity in lead III and early or no precordial transition in all. During all of these VAs, far-field electrograms in the His bundle (HB) region preceded the QRS onset. In all patients, ventricular pre-potentials were recorded during VAs while late potentials were recorded in sinus rhythm at the border of a localized low-voltage area underneath the aorta. Radiofrequency catheter ablation at the presumed sites of origin successfully eliminated VAs in five patients and was abandoned in the remaining three because the HB electrogram was recorded at that site. Conclusion Focal VAs may arise from the LV adjacent to the membranous septum as a part of the LV ostium, and broadens the spectrum of LV ostium VAs.
*This document does not cover atrial fibrillation, which is covered in the ACC/AHA/ESC guidelines... more *This document does not cover atrial fibrillation, which is covered in the ACC/AHA/ESC guidelines on the management of patients with atrial fibrillation found on the ACC, AHA, and ESC Web sites.
Uploads
Papers by Neal Kay