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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

View larger version (54K): [in a new window]   Figure 1 (A) Twelve-lead ECG in a 17-year-old male with syncope and palpitations who had successful ablation from the left sinus of Valsalva. Note the nonsustained ventricular tachycardia (VT) had left bundle branch block, inferior axis morphology with transition in V3 and rS pattern in lead I. (B) Identical pace mapping from the successful site above left coronary cusp is shown. The left side of the panel shows spontaneous nonsustained VT and the right-side panel shows the pace mapping at the successful site. The recordings V2 and V3 were obtained from sites lateral to the standard position because of placement of a defibrillator patch in the lower chest region.

View larger version (149K): [in a new window]   Figure 2 (A) 12-lead configuration of spontaneous ventricular tachycardia in a patient successfully ablated from the noncoronary cusp region. (B) Pace map at the successful site. Note left bundle branch block inferior axis morphology, precordial transition in V2 and a notched R-wave lead I.

View larger version (46K): [in a new window]   Figure 3 The local electrogram from the epicardial aspect in the patient in Figure 1 is shown on the left side of the panel. The ventricular electrogram precedes the surface QRS by 63 ms, but there is also a large atrial electrogram recorded at this site. The right side of the panel shows local activation recorded from the left aortic sinus of Valsalva where the ventricular tachycardia was successfully ablated. At this site the local ventricular electrogram preceded the surface QRS by 52 ms.

View larger version (122K): [in a new window]   Figure 4 High resolution computerized tomographic images of the heart, showing an oblique view. The aortic root and left coronary cusp are partly covered by the left atrial appendage. LA = left atrium; LAA = left atrial appendage; LCS = left coronary sinus.