Preferential Conduction Across the Ventricular Outflow Septum in Ventricular Arrhythmias Originating From the Aortic Sinus Cusp

Preferential Conduction Across the Ventricular Outflow Septum in Ventricular Arrhythmias Originating From the Aortic Sinus Cusp

Takumi Yamada, Yoshimasa Murakami, Naoki Yoshida, Taro Okada, Takeshi Shimizu, Junji Toyama, Yukihiko Yoshida, Naoya Tsuboi, Masahiro Muto, Yasuya Inden, Makoto Hirai, Toyoaki Murohara, Hugh T. McElderry, Andrew E. Epstein, Vance J. Plumb, G. Neal Kay

The present study showed 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 using electroanatomical mapping and pace mapping. A VT or PVCs originating from the aortic sinus cusp often show preferential conduction to the right ventricular outflow tract, which may render pace mapping or some algorithms using the electrocardiographic characteristics to predict the origin less reliable. In some of those cases, an insulated myocardial fiber across the ventricular outflow septum may exist.

Objectives

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.

Background

The myocardial network around the ventricular outflow tract is not well known.

Methods

We studied 70 patients with idiopathic VT (n = 23) or PVCs (n = 47) with a left bundle branch block and inferior QRS axis morphology. Electroanatomical mapping was performed in both the right ventricular outflow tract (RVOT) and aortic sinus cusp (ASC) during VT or PVCs.

Results

The earliest ventricular activation (EVA) was recorded in the RVOT in 55 patients (group R) and in the ASC in 15 (group A). In all group R patients, the closest pace map and successful ablation were achieved at the EVA site. Although a successful ablation was achieved at the EVA site in all group A patients, the closest pace map was obtained at the EVA site in 8 and RVOT in 7 (with an excellent pace map in 4). The stimulus to QRS interval was 0 ms during pacing from the RVOT and 36 ± 8 ms from the ASC. The distance between the EVA and perfect pace map sites in those 4 patients was 11.9 ± 3.0 mm.

Conclusions

Ventricular arrhythmias originating from the ASC often show preferential conduction to the RVOT, which may render pace mapping or some algorithms using the electrocardiographic characteristics less reliable. In some of those cases, an insulated myocardial fiber across the ventricular outflow septum may exist.