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Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp

Electrocardiographic characterization for guiding catheter ablation

Feifan Ouyang, MD^*,*, Parwis Fotuhi, MD^*, Siew Yen Ho, PhD, Joachim Hebe, MD^*, Marius Volkmer, MD^*, Masahiko Goya, MD^*, Mark Burns, MD^*, Matthias Antz, MD^*, Sabine Ernst, MD^*, Riccardo Cappato, MD^* and Karl-Heinz Kuck, MD^*

^* II. Med. Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany
Department of Paediatrics, National Heart and Lung Institute and Royal Brompton Hospital, Imperial College School of Medicine, London, United Kingdom

View larger version (16K): [in a new window]   Figure 1 Example of electrocardiographic analysis of clinical arrhythmias: leads aVF, V1 and V4 of a normal sinus beat, followed by the first beat of repetitive monomorphic ventricular tachycardia. A = total QRS duration, measured from the earliest onset in lead V4 to the latest activation in lead aVF (ms); B = R-wave duration, determined in lead V1 from the QRS onset to the R-wave transaction point of the R-wave with the isoelectric line (ms); C = R-wave amplitude, measured from the peak to the isoelectric line (mV); D = S-wave amplitude measured from the cusp to the isoelectric line (mV).

View larger version (23K): [in a new window]   Figure 2 Mapping catheter recordings of a sinus beat and the first beat of repetitive monomorphic ventricular tachycardia (RMVT) at the successful ablation sites in two different patients. Each panel shows surface electrocardiographic leads I, III and V4, as well as the bipolar and unipolar signals recorded from the mapping catheter. (A) Earliest ventricular activation preceding onset of the QRS complex by 34 ms in a patient with RMVT originating from the left coronary aortic sinus. The unipolar signal (AS uni) also has a QS morphology, but is activated later than the bipolar signals (AS 1–2). Please note that a low-amplitude presystolic potential (arrow) appears during RMVT, although this potential is the second component of the "ventricular signal" (asterisk) during sinus rhythm. (B) Earliest low-amplitude late-diastolic ventricular potential (arrow) preceding onset of the QRS complex by 97 ms in a patient with RMVT originating from the left coronary aortic sinus cusp. As in part A, this potential is also seen as the second component of the "ventricular signal" during sinus rhythm (asterisk). A = atrial potential; V = ventricular potential.

View larger version (39K): [in a new window]   Figure 3 Anatomic location of the origin of the arrhythmia, with corresponding 12-lead electrocardiographic morphology. Note the different morphology in leads V1 and V2 with respect to the anatomic origin. L = left coronary aortic sinus; N = noncoronary aortic sinus; R = right coronary aortic sinus; RVOT = right ventricular outflow tract.

View larger version (13K): [in a new window]   Figure 4 Plot of the indexes of R-wave duration (A) and R/S amplitude (B) in patients with repetitive monomorphic ventricular tachycardia originating from the superior septal right ventricular outflow tract (RVOT) and aortic sinus cusp (ASC).

View larger version (70K): [in a new window]   Figure 5 Right (30°) and left (45°) anterior oblique (RAO and LAO, respectively) radiographic views of the mapping catheter (Map) at the successful ablation site in the left coronary sinus cusp. The mapping catheter was located below the ostium of the left main coronary artery (LMCA). CS = decapolar catheter inside the coronary sinus, with the distal electrode inside the great cardiac vein; His = decapolar catheter at the His bundle region; JC = 5F left Judkin’s catheter.

View larger version (122K): [in a new window]   Figure 6 Heart specimens illustrating the anatomic arrangement between the right ventricular outflow tract (RVOT) and the aortic sinuses. (a) Viewed anteriorly, the RVOT passes leftward and superior to the aortic valve. (b) The posterior view shows the left (L) and right (R) coronary aortic sinuses adjacent to the pulmonary infundibulum. The noncoronary (N) aortic sinus is remote from the RVOT, but is related to the mitral valve (MV) and central fibrous body. The dotted line marks the ventriculo-arterial junction (VAJ) between the wall of the pulmonary trunk (PT) and right ventricular muscle. Note the cleavage plane behind the pulmonary infundibulum and in front of the aortic root. (c and d) These simulated parasternal long-axis sections show two halves of the same heart and display the left and right coronary orifices. The right- and left-facing pulmonary sinuses (R and L in circles, respectively) are situated superior to the aortic sinuses. The dotted line marks the epicardial aspect of the subpulmonary infundibulum in the so-called "septal" area. LAA = left atrial appendage; LCA = left coronary artery; LV = left ventricle; RAA = right atrial appendage; RCA = right coronary artery; SCV = superior vena cava; TV = tricuspid valve; VS = ventricular septum.