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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

View larger version (25K): [in a new window]   Figure 1 Representative 12-lead electrocardiograms of premature ventricular contractions originating from the anterolateral (A), posterior (B), and posteroseptal (C) portions of the mitral annulus. Arrows indicate "notching" of the late phase of the QRS complex in the inferior leads.

View larger version (86K): [in a new window]   Figure 2 Site of successful ablation of a premature ventricular contraction originating from the anterolateral portion of the mitral annulus (Patient #1). (A) Intracardiac recordings. During the premature ventricular contraction, a low-amplitude presystolic potential recorded by the ablation catheter (ABL) preceded the onset of the QRS complex by 34 ms (arrow). The timing of the second peak of the "notched" R-wave corresponded precisely with that of the activation of the right ventricular free wall (dotted line), which was recorded by the catheter at the high right atrium (HRA). (B) Radiographs obtained in right anterior oblique (RAO, 35°) and left anterior oblique (LAO, 45°) projections show ablation sites. A distal electrode of the ablation catheter was positioned at the anterolateral-mitral annulus. A = atrial activation; Bi. = bipolar electrogram; Uni. = unipolar electrogram; V = ventricular activation.

View larger version (86K): [in a new window]   Figure 3 Site of successful ablation of a premature ventricular contraction originating from the posterior mitral annulus (Patient #12). (A) Intracardiac recordings. During the premature ventricular contraction, a distinct presystolic potential recorded by the ablation catheter preceded the onset of the QRS complex by 60 ms (arrow). The timing of the second peak of the "notched" Q-wave corresponded precisely with that of activation of the right ventricular free wall (dotted line), which was recorded with the catheter at the high right atrium (HRA). (B) Radiographs obtained in the right anterior oblique (RAO, 35°) and left anterior oblique (LAO, 45°) projections show ablation sites. A distal electrode of the ablation catheter was positioned at the posterior mitral annulus. A = atrial activation; Bi. = bipolar electrogram; Uni. = unipolar electrogram; V = ventricular activation.

View larger version (81K): [in a new window]   Figure 4 QRS duration and notching. (A) Total duration of the QRS complex of mitral annulus (MA) ventricular tachycardia (VT)/premature ventricular contraction (PVC). In anterolateral (AL) and posterior (P) MAVT/PVC, the QRS duration was significantly longer than in the posteroseptal (PS)-MAVT/PVC. The QRS duration was >140 ms in all AL-MAVT/PVC and Pos-MAVT/PVC, whereas it was <140 ms in all PS-MAVT/PVC. (B) Twelve-lead ECGs obtained during pacing from the AL (a), P (b), and PS (c) portion of the MA. Arrows indicate "notching" of the late phase of the QRS complex in the inferior leads.

View larger version (35K): [in a new window]   Figure 5 Proposed algorithm to predict the precise focus of mitral annulus (MA) ventricular tachycardia (VT)/premature ventricular contraction (PVC) based on the QRS wave configuration on 12-lead electrocardiographic recordings.