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  • DOI: 10.1161/CIRCEP.113.000870

    1

    Reentrant Ventricular Tachycardia Originating from the Periaortic Region in

    the Absence of Overt Structural Heart Disease

    Running title: Nagashima et al.; Periaortic VT without structural heart disease

    Koichi Nagashima, MD, PhD; Usha B. Tedrow, MD, MSc.; Bruce A. Koplan, MD; MPH;

    Gregory F. Michaud, MD; Roy M. John, MD, PhD; Laurence M. Epstein, MD; Michifumi

    Tokuda, MD, PhD; Keiichi Inada, MD, PhD; Tobias R. Reichlin, MD; Justin P. Ng, MD; Chirag

    R. Barbhaiya, MD; Eyal Nof, MD; Thomas M. Tadros, MD; William G. Stevenson, MD

    Arrhythmia Unit, Cardiovascular Division, Brigham and Womens Hospital, Boston, MA

    Correspondence:

    William G. Stevenson, M.D.

    Cardiovascular Division

    Brigham and Womens Hospital

    75 Francis St.

    Boston, MA, USA 02115

    Tel: 1-857-307-1948

    Fax: 1-857-307-1944

    E-mail: wstevenson@partners.org

    Journal Subject Codes: [106] Electrophysiology, [171] Electrocardiology

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  • DOI: 10.1161/CIRCEP.113.000870

    2

    Abstract:

    Background - In the absence of overt structural heart disease most left ventricular outflow tract

    (LVOT) ventricular tachycardias (VTs) have a focal origin and are benign. We hypothesized that

    multiple morphologies (MM) of inducible LVOT VT may indicate a scar-related VT that can

    mimic idiopathic VT.

    Methods and Results - Of 54 consecutive patients referred for ablation of sustained OT VT

    without overt structural heart disease 24 had LVOT VT; 10 had MMVT and 14 had a single VT

    (SM). The MM group were older (70.34.3 vs. 53.915.9 years p=0.004), had more

    hypertension (100% vs. 29%, P=0.0006), had longer PR intervals and QRS durations than the

    SM group. In contrast to the SM group, the MM group VTs had features consistent with

    reentry including induction by programmed stimulation without isoproterenol, entrainment in

    some and abnormal electrograms in the periaortic area. Periaortic region voltages suggested

    scar in the MM group, but not the SM group. Magnetic resonance imaging in 2 MM patients

    was consistent with scar, but not in 10 SM patients. Longer radiofrequency applications were

    required in the MM group than the SM group. At a median follow-up of 9.7 (3.0, 32.0) months,

    recurrences tended to be more frequent in the MM group than the SM group (70% vs. 22%,

    P=0.07).

    Conclusions - VTs from small regions of periaortic scar can mimic idiopathic VT but are

    suggested by multiple VT morphologies and are more difficult to ablate. Whether these

    patients are at greater risk, as feared for other scar-related VTs, warrants further study.

    Key words: ventricular tachycardia, catheter ablation, reentry, periaortic region, structural normal heart

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  • DOI: 10.1161/CIRCEP.113.000870

    3

    Introduction

    Ventricular tachycardia (VT) originating from the periaortic region can occur in the absence of

    structural heart disease.1, 2 These VTs are generally categorized as idiopathic and often have

    features consistent with triggered activity due to delayed after depolarizations.3, 4 A single

    morphology of VT originating from a focal site is typical, although exceptions having multiple

    morphologies of VTs have been reported.5 Areas of ventricular scar can occur along the valve

    annuli in cardiomyopathies and give rise to VT that often has characteristics consistent with

    reentry. We have observed what appear to be scar-related VTs from the periaortic area in

    patients with no other evidence of structural heart disease, but these have not been well described.

    Some patients have multiple morphologies of VT that is more consistent with scar-related VT

    than idiopathic focal VT. The aim of this study is to characterize the VTs and VT substrate that

    gives rise to periaortic VT; and specifically to assess the presence of electrogram evidence of

    scar in the region and the relation between VT characteristics, including multiple morphologies

    of VT, and scar.

    Methods

    Patient characteristics

    From a consecutive series of 54 patients (32 male; age 54.214.0 years) who underwent ablation

    at our institution for sustained monomorphic VT (SMVT) originating from outflow tract (OT)

    area in the absence of structural heart disease from January 2004 to April 2013, the 24 patients

    who had SMVT originating from the periaortic region were included. Patients with a clinical

    history of only nonsustained (NS) arrhythmias were excluded. All patients underwent an

    assessment for the presence of overt structural heart disease with physical examination, 12-lead

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    athic focal VT. The aim of this study is to characterize the VTs and VT substrat

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  • DOI: 10.1161/CIRCEP.113.000870

    4

    electrocardiography (ECG), chest x-ray, transthoracic echocardiography (TTE), exercise or

    pharmacologic stress testing and/or coronary angiography. Magnetic resonance imaging (MRI)

    was often limited by prior implantable cardioverter defibrillator (ICD) placement and was

    performed in only 12 patients. Patients with structural heart disease defined as a history of

    coronary artery disease, myocarditis, infiltrative heart disease, valvular heart disease,

    hypertensive heart disease with depressed ventricular function [Left ventricular ejection fraction

    (LVEF)

  • DOI: 10.1161/CIRCEP.113.000870

    5

    isoproterenol and/or epinephrine. The endpoint of ventricular stimulation was the induction of

    SMVT lasting > 30 seconds or requiring termination because of hemodynamic intolerance or a

    shortest interstimulus interval of 180 to 200 ms. At the end of the procedure, the same

    stimulation protocol was repeated. Acute complete success was defined as the absen

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