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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Three-Dimensional Electroanatomical Voltage Mapping and Histologic Evaluation of Myocardial Substrate in Right Ventricular Outflow Tract Tachycardia

Domenico Corrado, MD, PhD^_*,_*, Cristina Basso, MD, PhD, Loira Leoni, MD, PhD^_*, Barbara Tokajuk, MD, PhD^_*, Pietro Turrini, MD, PhD^_*, Barbara Bauce, MD, PhD^_*, Federico Migliore, MD^_*, Andrea Pavei, MD^_*, Giuseppe Tarantini, MD, PhD^_*, Massimo Napodano, MD^_*, Angelo Ramondo, MD^_*, Gianfranco Buja, MD^_*, Sabino Iliceto, MD^_* and Gaetano Thiene, MD

^_* Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padua, Italy
Department of Medical-Diagnostic Sciences, University of Padua Medical School, Padua, Italy.

Manuscript received June 11, 2007; revised manuscript received October 24, 2007, accepted November 8, 2007.

^_* Reprint requests and correspondence: Dr. Domenico Corrado, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Via Giustiniani, 2-35121 Padova, Italy. (Email: domenico.corrado{at}unipd.it).

Objectives: We tested whether 3-dimensional electroanatomical voltage mapping (EVM) may help in the differential diagnosis between idiopathic right ventricular outflow tract (RVOT) tachycardia and arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D).

Background: Right ventricular EVM has been demonstrated to reliably identify low-voltage regions ("electroanatomical scar"), which in patients with ARVC/D correspond to areas of fibrofatty myocardial replacement.

Methods: The study population comprised 27 patients (15 men and 12 women, age 33.9 ± 8 years) with RVOT tachycardia and no echocardiographic/angiographic evidence of right ventricular (RV) dilation/dysfunction, who underwent EVM and endomyocardial biopsy (EMB) for characterization of ventricular tachycardia (VT) substrate before catheter ablation.

Results: Electroanatomical voltage mapping was normal in 20 of 27 patients (74%, group A), with electrogram voltage >1.5 mV throughout the RV. The other 7 patients (26%, group B) showed 1 (1.4 ± 07) RV electroanatomical scar area(s) (bipolar voltage <0.5 mV) that correlated with fibrofatty myocardial replacement at EMB (p < 0.001). Clinical predictors of RV scar were right precordial QRS prolongation (p < 0.001) and VT inducibility (p = 0.001). Catheter ablation successfully eliminated VT in 18 of 20 patients (90%). During a follow-up of 41 ± 8 months, 3 of 7 patients (43%) from group B received an implantable defibrillator because of life-threatening ventricular arrhythmias, compared with no patients from group A (p = 0.016).

Conclusions: An early/minor form of ARVC/D may mimic idiopathic RVOT tachycardia. Electroanatomical voltage mapping is able to identify RVOT tachycardia due to concealed ARVC/D by detecting RVOT electroanatomical scars that correlate with fibrofatty myocardial replacement at EMB and predispose to sudden arrhythmic death.

Abbreviations and Acronyms   ARVC/D = arrhythmogenic right ventricular cardiomyopathy/dysplasia   CMR = cardiac magnetic resonance   EMB = endomyocardial biopsy   EVM = electroanatomical voltage mapping   LV = left ventricle/ventricular   RV = right ventricle/ventricular   RVOT = right ventricular outflow tract   SAECG = signal-averaged electrocardiogram   VT = ventricular tachycardia

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