CLINICAL STUDY: CARDIAC ARRHYTHMIAS
Ablation of electrograms with an isolated, delayed component as treatment of unmappable monomorphic ventricular tachycardias in patients with structural heart disease
Angel Arenal, MD*,*,
Esteban Glez-Torrecilla, MD*,
Mercedes Ortiz, PhD*,
Julian Villacastín, MD*,
Javier Fdez-Portales, MD*,
Elena Sousa, MD*,
Silvia del Castillo, MD*,
Leopoldo Perez de Isla, MD*,
Javier Jimenez, MD* and
Jesus Almendral, MD*
* Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
Manuscript received February 7, 2002;
revised manuscript received September 10, 2002,
accepted September 20, 2002.
* Reprint requests and correspondence: Dr. Angel Arenal, Laboratorio de Electrofisiología, Departamento de Cardiología, Hospital General Universitario Gregorio Marañón, C/Dr. Esquerdo 46, 28007 Madrid, Spain.
arenal{at}doymanet.es
OBJECTIVES: We sought to evaluate the feasibility of identifying and ablating the substrate of unmappable ventricular tachycardia (VT).
BACKGROUND: Noninducible and nonstable VT cannot be ablated by the conventional approach.
METHODS: We studied 24 patients with documented monomorphic VT. Twenty-one patients had ischemic cardiomyopathy, two had nonischemic cardiomyopathy, and one had tetralogy of Fallot. Twelve patients had an implantable cardioverter-defibrillator. Conventional activation mapping was not possible in 18 patients: at least 1 of the clinical VTs or the clinical VT was not inducible in 12 patients, and VT was not tolerated in 6 patients. This group had experienced between 1 and 106 VT episodes in the month before the ablation procedure. Endocardial electroanatomic activation maps (Carto System) during sinus rhythm (SR) and right ventricular apex (RVA) pacing were obtained to define areas for which an electrogram displayed isolated, delayed components (E-IDC). These electrograms were characterized by double or multiple components separated by  50 ms.
RESULTS: One area of E-IDC was recorded in 20 patients, and 2 or more were recorded in 4 patients. In 23 patients, these areas were detected during RVA pacing; in only 14 during SR. An E-IDC area related to the clinical VT was identified in each patient. Ablation guided by E-IDC suppressed all but one clinical VT whose inducibility suppression was tested. During a follow-up period of 9 ± 4 months, three patients had recurrences of the ablated VT and two of a different VT.
CONCLUSIONS: Electrograms with IDCs related to clinical VT can be identified in the majority of patients during RVA pacing. Radiofrequency ablation of E-IDC seems effective in controlling unmappable VT.
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Abbreviations and Acronyms
| | E-IDC | | electrogram displaying isolated | = delayed component | | E-LIDC | | electrogram displaying latest isolated | = delayed component | | E-QRS | | electrogram’s QRS interval | | ICD | | implantable cardioverter-defibrillator | | RFA | | radiofrequency ablation | | RVA | | right ventricular apex | | SMVT | | sustained monomorphic ventricular tachycardia | | S-QRS | | stimulus to QRS interval | | SR | | sinus rhythm | | VT | | ventricular tachycardia |
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