This Article Figures Only Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kanagaratnam, L. Articles by Natale, A. Search for Related Content PubMed PubMed Citation Articles by Kanagaratnam, L. Articles by Natale, A.

CLINICAL STUDY

Ventricular tachycardias arising from the aortic sinus of valsalva: an under-recognized variant of left outflow tract ventricular tachycardia

Logan Kanagaratnam, MD^*, Gery Tomassoni, MD, Robert Schweikert, MD^*, Stephen Pavia, MD^*, Dianna Bash, RN^*, Salwa Beheiry, RN, Mark Niebauer, MD, PhD^*, Walid Saliba, MD^*, Mina Chung, MD^*, Patrick Tchou, MD^* and Andrea Natale, MD^*

^* Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Central Baptist Hospital, Lexington, Kentucky, USA

Manuscript received August 18, 2000; revised manuscript received November 29, 2000, accepted December 22, 2000.

Reprint requests and correspondence: Dr. Andrea Natale, F15, Section of Cardiac Electrophysiology and Pacing, Department of Cardiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195
natalea{at}ccf.org

OBJECTIVES

To describe a normal heart left bundle branch block, inferior axis ventricular tachycardia (VT), that could not be ablated from the right or left ventricular outflow tracts.

BACKGROUND

Whether these VTs are epicardial and can be identified by a specific electrocardiographic pattern is unclear.

METHODS

Twelve patients with normal heart left bundle branch block, inferior axis VT and previously failed ablation were included in this study. Together with mapping in the right and left ventricular outflow tracts, we obtained percutaneous epicardial mapping in the first five patients and performed aortic sinus of Valsalva mapping in all patients.

RESULTS

No adequate pace mapping was observed in the right and left ventricular outflow tracts. Earliest ventricular activation was noted in the epicardium and the aortic cusps. All patients were successfully ablated from the aortic sinuses of Valsalva (95% CI 0% to 18%). The electrocardiographic pattern associated with this VT was left bundle branch block, inferior axis and early precordial transition with Rs or R in V₂ or V₃. Ventricular tachycardia from the left sinus had rS pattern in lead I, and VT from the noncoronary sinus had a notched R wave in lead I. None of the patients had complications and all remained arrhythmia-free at a mean follow-up of 8 ± 2.6 months.

CONCLUSIONS

Normal heart VT with left bundle branch block, inferior axis and early precordial transition can be ablated in the majority of patients from either the left or the noncoronary aortic sinus of Valsalva.

Abbreviations and Acronyms   ECG = electrocardiogram   LBBB = left bundle branch block   LVOT = left ventricular outflow tract   RVOT = right ventricular outflow tract   VT = ventricular tachycardia

This article has been cited by other articles:

				A. Rillig, U. Meyerfeldt, R. Birkemeyer, and W. Jung Ablation within the sinus of Valsalva for treatment of supraventricular and ventricular tachycardias: what is known so far? Europace, September 1, 2009; 11(9): 1142 - 1150. [Abstract] [Full Text] [PDF]

				N. Tabatabaei and S. J. Asirvatham Supravalvular Arrhythmia: Identifying and Ablating the Substrate Circ Arrhythm Electrophysiol, June 1, 2009; 2(3): 316 - 326. [Full Text] [PDF]

				E. M. Aliot, W. G. Stevenson, J. M. Almendral-Garrote, F. Bogun, C. H. Calkins, E. Delacretaz, P. D. Bella, G. Hindricks, P. Jais, M. E. Josephson, et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA) Europace, June 1, 2009; 11(6): 771 - 817. [Full Text] [PDF]

				T. Yamada, S. H. Litovsky, and G. N. Kay The Left Ventricular Ostium: An Anatomic Concept Relevant to Idiopathic Ventricular Arrhythmias Circ Arrhythm Electrophysiol, December 1, 2008; 1(5): 396 - 404. [Full Text] [PDF]

				D. L. Packer, S. B. Johnson, M. W. Kolasa, T. J. Bunch, B. D. Henz, and Y. Okumura New generation of electro-anatomic mapping: full intracardiac ultrasound image integration Europace, November 1, 2008; 10(suppl_3): iii35 - iii41. [Abstract] [Full Text] [PDF]

				T. Yamada, H. T. McElderry, H. Doppalapudi, Y. Murakami, Y. Yoshida, N. Yoshida, T. Okada, N. Tsuboi, Y. Inden, T. Murohara, et al. Idiopathic Ventricular Arrhythmias Originating From the Aortic Root: Prevalence, Electrocardiographic and Electrophysiologic Characteristics, and Results of Radiofrequency Catheter Ablation J. Am. Coll. Cardiol., July 8, 2008; 52(2): 139 - 147. [Abstract] [Full Text] [PDF]

				K. S. Srivathsan, T. J. Bunch, S. J. Asirvatham, W. D. Edwards, P. A. Friedman, T. M. Munger, S. C. Hammill, Y.-M. Cha, P. A. Brady, A. Jahangir, et al. Mechanisms and Utility of Discrete Great Arterial Potentials in the Ablation of Outflow Tract Ventricular Arrhythmias Circ Arrhythm Electrophysiol, April 1, 2008; 1(1): 30 - 38. [Abstract] [Full Text] [PDF]

				T. Yamada, H.T. McElderry, H. Doppalapudi, and G. N. Kay Ventricular tachycardia with a myocardial fibre travelling from the origin in the right aortic sinus cusp to the epicardial breakout site of the right ventricular outflow tract Europace, April 1, 2008; 10(4): 469 - 470. [Abstract] [Full Text] [PDF]

				T. Yamada, Y. Murakami, N. Yoshida, T. Okada, T. Shimizu, J. Toyama, Y. Yoshida, N. Tsuboi, M. Muto, Y. Inden, et al. Preferential Conduction Across the Ventricular Outflow Septum in Ventricular Arrhythmias Originating From the Aortic Sinus Cusp J. Am. Coll. Cardiol., August 28, 2007; 50(9): 884 - 891. [Abstract] [Full Text] [PDF]

				H. Huang, X. Wang, F. Ouyang, and M. Antz Catheter ablation of anteroseptal accessory pathway in the non-coronary aortic sinus Europace, December 1, 2006; 8(12): 1041 - 1044. [Abstract] [Full Text] [PDF]

				O. A. Obel, A. d'Avila, P. Neuzil, E. B. Saad, J. N. Ruskin, and V. Y. Reddy Ablation of Left Ventricular Epicardial Outflow Tract Tachycardia From the Distal Great Cardiac Vein J. Am. Coll. Cardiol., November 7, 2006; 48(9): 1813 - 1817. [Abstract] [Full Text] [PDF]

				Developed in Collaboration With the European Heart, D. P. Zipes, A. J. Camm, M. Borggrefe, A. E. Buxton, B. Chaitman, M. Fromer, G. Gregoratos, G. Klein, A. J. Moss, et al. 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., September 5, 2006; 48(5): e247 - e346. [Full Text] [PDF]

				Writing Committee Members, D. P. Zipes, A. J. Camm, M. Borggrefe, A. E. Buxton, B. Chaitman, M. Fromer, G. Gregoratos, G. Klein, A. J. Moss, et al. 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 Europace, September 1, 2006; 8(9): 746 - 837. [Full Text] [PDF]

				F. Ouyang, J. Ma, S. Y. Ho, D. Bansch, B. Schmidt, S. Ernst, K.-H. Kuck, S. Liu, H. Huang, M. Chen, et al. Focal Atrial Tachycardia Originating From the Non-Coronary Aortic Sinus: Electrophysiological Characteristics and Catheter Ablation J. Am. Coll. Cardiol., July 4, 2006; 48(1): 122 - 131. [Abstract] [Full Text] [PDF]

				D. V. Daniels, Y.-Y. Lu, J. B. Morton, P. A. Santucci, J. G. Akar, A. Green, and D. J. Wilber Idiopathic Epicardial Left Ventricular Tachycardia Originating Remote From the Sinus of Valsalva: Electrophysiological Characteristics, Catheter Ablation, and Identification From the 12-Lead Electrocardiogram Circulation, April 4, 2006; 113(13): 1659 - 1666. [Abstract] [Full Text] [PDF]

				H. Tada, S. Ito, S. Naito, K. Kurosaki, S. Kubota, A. Sugiyasu, T. Tsuchiya, K. Miyaji, M. Yamada, Y. Kutsumi, et al. Idiopathic ventricular arrhythmia arising from the mitral annulus: A distinct subgroup of idiopathic ventricular arrhythmias J. Am. Coll. Cardiol., March 15, 2005; 45(6): 877 - 886. [Abstract] [Full Text] [PDF]

				Y. Sekiguchi, K. Aonuma, A. Takahashi, Y. Yamauchi, H. Hachiya, Y. Yokoyama, Y. Iesaka, and M. Isobe Electrocardiographic and electrophysiologic characteristics of ventricular tachycardia originating within the pulmonary artery J. Am. Coll. Cardiol., March 15, 2005; 45(6): 887 - 895. [Abstract] [Full Text] [PDF]

				H. Tanner, G. Hindricks, P. Schirdewahn, R. Kobza, A. Dorszewski, C. Piorkowski, J.-H. Gerds-Li, and H. Kottkamp Outflow tract tachycardia with R/S transition in lead V3: Six different anatomic approaches for successful ablation J. Am. Coll. Cardiol., February 1, 2005; 45(3): 418 - 423. [Abstract] [Full Text] [PDF]

				C. Timmermans, L.-M. Rodriguez, H. J.G.M. Crijns, A. F.M. Moorman, and H. J.J. Wellens Idiopathic Left Bundle-Branch Block-Shaped Ventricular Tachycardia May Originate Above the Pulmonary Valve Circulation, October 21, 2003; 108(16): 1960 - 1967. [Abstract] [Full Text] [PDF]

				A. F. M. MOORMAN and V. M. CHRISTOFFELS Cardiac Chamber Formation: Development, Genes, and Evolution Physiol Rev, October 1, 2003; 83(4): 1223 - 1267. [Abstract] [Full Text] [PDF]

				F. Ouyang, M. Antz, F. T. Deger, D. Bansch, A. Schaumann, S. Ernst, and K.-H. Kuck An Underrecognized Subepicardial Reentrant Ventricular Tachycardia Attributable to Left Ventricular Aneurysm in Patients With Normal Coronary Arteriograms Circulation, June 3, 2003; 107(21): 2702 - 2709. [Abstract] [Full Text] [PDF]

				H. Kottkamp and G. Hindricks Right ventricular tachycardia--arrhythmogenic right ventricular cardiomyopathy or idiopathic? Eur. Heart J., May 1, 2003; 24(9): 787 - 788. [Full Text] [PDF]

				P. A. Friedman, S. J. Asirvatham, S. Grice, M. Glikson, T. M. Munger, R. F. Rea, W. K. Shen, A. Jahanghir, D. L. Packer, and S. C. Hammill Noncontact mapping to guide ablation of right ventricular outflow tract tachycardia J. Am. Coll. Cardiol., June 5, 2002; 39(11): 1808 - 1812. [Abstract] [Full Text] [PDF]

				F. Ouyang, P. Fotuhi, S. Y. Ho, J. Hebe, M. Volkmer, M. Goya, M. Burns, M. Antz, S. Ernst, R. Cappato, et al. Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp: Electrocardiographic characterization for guiding catheter ablation J. Am. Coll. Cardiol., February 6, 2002; 39(3): 500 - 508. [Abstract] [Full Text] [PDF]