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CLINICAL RESEARCH: VENTRICULAR TACHYCARDIA

Idiopathic ventricular arrhythmia arising from the mitral annulus

A distinct subgroup of idiopathic ventricular arrhythmias

Hiroshi Tada, MD^*,*, Sachiko Ito, MD^*, Shigeto Naito, MD^*, Kenji Kurosaki, MD^*, Shoichi Kubota, MD, Aiko Sugiyasu, MD, Taketsugu Tsuchiya, MD, Kohei Miyaji, MD^*, Minoru Yamada, MD^*, Yasunori Kutsumi, MD, Shigeru Oshima, MD^*, Akihiko Nogami, MD and Koichi Taniguchi, MD, FACC^*

^* Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan
Division of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
Fukui Chuo Clinic, Fukui, Japan
Division of Cardiology, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan

Manuscript received July 15, 2004; revised manuscript received October 20, 2004, accepted December 6, 2004.

^* Reprint requests and correspondence: Dr. Hiroshi Tada, Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma 371-0004, Japan (Email: tada.h{at}cvc.pref.gunma.jp).

OBJECTIVES: We sought to clarify the prevalence and characteristics of idiopathic ventricular tachycardia or premature ventricular contraction originating from the mitral annulus (MAVT/PVC).

BACKGROUND: Recent case reports have presented patients with MAVT/PVC.

METHODS: Electrocardiographic (ECG) characteristics and the results of electrophysiologic investigation and radiofrequency catheter ablation (RFCA) were analyzed in 352 patients with symptomatic idiopathic ventricular tachycardia (IVT)/premature ventricular contraction (PVC).

RESULTS: Nineteen cases of IVT/PVC (5%) represented MAVT/PVC. Of these, 11 (58%) originated from the anterolateral portion of the mitral annulus (AL-MAVT/PVC), and 2 (11%) arose from the posterior portion (Pos-MAVT/PVC). The remaining six cases of MAVT/PVC (31%) had posteroseptal origin (PS-MAVT/PVC). In all patients, an S-wave was present in lead V₆. The QRS polarity in inferior leads and leads I and aVL was useful for differentiating AL-MAVT/PVC from Pos-MAVT/PVC or PS-MAVT/PVC. The Pos-MAVT/PVC had an Rs pattern in lead I and an R pattern in lead V₁, whereas PS-MAVT/PVC invariably had an R pattern in lead I and a negative QRS component in lead V₁. The AL-MAVT/PVC and Pos-MAVT/PVC showed a longer QRS duration than the PS-MAVT/PVC (p < 0.001), and all had late-phase "notching" of the QRS complex in inferior leads. In all patients, RFCA eliminated MAVT/PVC, with no recurrences during follow-up for 21 ± 15 months.

CONCLUSIONS: Mitral annular VT/PVC is a rare but distinct subgroup of IVT/PVC. MAVT/PVC origin could be determined by ECG analysis. The AL and PS sites of the MA were preferential.

Abbreviations and Acronyms   AL = anterolateral   IVT = idiopathic ventricular tachycardia   LV = left ventricle/ventricular   MA = mitral annulus/annular   PVC = premature ventricular contractions   OT = outflow tract   Pos = posterior   PS = posteroseptal   PVC = premature ventricular contraction   RFCA = radiofrequency catheter ablation   RV = right ventricle/ventricular   VT = ventricular tachycardia

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