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CLINICAL RESEARCH: HEART RHYTHM DISORDER

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

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

^_* Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama
Division of Cardiology, Aichi Prefectural Cardiovascular and Respiratory Center, Ichinomiya, Japan
Division of Cardiology, Nagoya Dai-ni Red Cross Hospital, Cardiovascular Center, Nagoya, Japan
Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Manuscript received January 31, 2007; revised manuscript received April 16, 2007, accepted May 5, 2007.

^_* Reprint requests and correspondence: Dr. Takumi Yamada, Division of Cardiovascular Diseases, Cardiac Rhythm Management Laboratory, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd Avenue South, Birmingham, Alabama 35294-0019. (Email: takumi-y{at}fb4.so-net.ne.jp).

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.

Abbreviations and Acronyms   ASC = aortic sinus cusp   EVA = earliest ventricular activation   PVC = premature ventricular contraction   RF = radiofrequency   RVOT = right ventricular outflow tract   St-QRS = the interval from the pacing stimulus to the onset of the QRS   VT = ventricular tachycardia

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