Outflow Tract Ventricular Tachycardia Always Benign?

Transcription

1 Outflow Tract Ventricular Tachycardia Always Benign? Arash Arya, M.D. Department of Interventional Electrophysiology Heart Center University of Leipzig

2 Disclosures: NONE

3 Outflow Ventricular Tachycardia Outflow tract ventricular tachycardias (OT-VT) are the most common form of idiopathic VT which accounts for nearly 10% of all patients referred for evaluation of VT % of cases OT-VT originates from the right ventricular outflow tract. It is also important to distinguish Malignant from Benign form of OTVT. It is important to distinguish an idiopathic RVOT VT from a VT caused by structural heart diseases. All patients presenting with OT-VT require an evaluation for organic heart diseases or genetic syndromes associated with sudden death.

4 Outflow Tract Ventricular Tachycardia Tachycardia Induced Cardiomyopathy* Male, 25 years old; First Diagnosis 2007, Asymptomatic; Good LVEF August 2008 ~ PVCs/Day May 2009 LVEDD: 63 mm; EF: 32%, diffuse HK May 2009 MRI, EF: 30%. The patient admitted for catheter ablation *Courtesy of Valentina Romano, M.D. Heart Center University of Leipzig

5 Outflow Tract Ventricular Tachycardia Tachycardia Induced Cardiomyopathy

6 Outflow Tract Ventricular Tachycardia Tachycardia Induced Cardiomyopathy I II III avr avl avf V1 V2 V3 V4 V5 V6

7 Outflow Tract Ventricular Tachycardia Tachycardia Induced Cardiomyopathy I II His III ABL RAO avr avl avf RV V1 V2 V3 His ABL LAO V4 V5 MA CS V6 RV

8 Outflow Tract Ventricular Tachycardia Tachycardia Induced Cardiomyopathy I II His ABL III avr LCC RAO avl avf LVOT RV V1 V2 V3 V4 V5 V6 His ABL RV CS LAO

9 Outflow Tract Ventricular Tachycardia Tachycardia Induced Cardiomyopathy

10 Outflow Ventricular Tachycardia Management Medical Ablation Syncope* Fast VT>230 bpm* PVC>20000 per day? TICMP Short coupled (R-on-T)* Symptomatic despite OMT Side effects (Med Tx) * Malignant OTVT

11 Idiopathic Ventricular Tachycardia OT-PVC induced PMVT/VF* Female, 21 years old. considered completely healthy July 2010: during bicycle tour on a hot summer day, she developed syncope admission to a hospital; there she developed another syncope; no ECG monitoring at the time of syncope! *Courtesy of Valentina Romano, M.D. Heart Center University of Leipzig

12 I II III avr avl avf V1 V2 V3 V4 V5 V6

13 Case Presentation syncope during physical / mental stress QTc-prolongation to > 600 ms grandfather died aged 36 (SCD) genetic test: KCNH2 Mutation (LQTS2) treatment with Betablocker patient received a defibrillator vest

14 Case Presentation

15 CS RVOT LCC LVOT

16 Among 101 patients without structural heart disease in whom RFCA was conducted for idiopathic OTVT (RVOT), the authors examined the clinical characteristics in 16 patients with spontaneous VF/PMVT initiated by the RVOT-PVCs. Noda et al. JACC 2005

17 How can we distinguish the malignant form from the benign form of idiopathic VT originating from RVOT?* * Shimizu W.. Heart Rhythm 2009

18 Possible mechanism of the malignant form of idiopathic VT originating from RVOT* It is speculated that functional block and/or delayed conduction by rapid firing due to triggered activity or microreentry arising from a single focus led to chaotic ventricular conduction, thus causing VF /PMVT. It is also speculated that rapid firing from close multiple foci one after another produces polymorphic morphological changes in the QRS configuration, since other VPCs with slightly different QRS morphology often appeared after eliminating the initial target VPCs by RFA. * Shimizu W. Heart Rhythm 2009

19 Outflow Ventricular Tachycardia Management Medical Ablation Syncope* Fast VT>230 bpm* PVC> per day? TICMP Short coupled (R-on-T)* Symptomatic despite OMT Side effects (Med Tx) * Malignant OTVT

20 Outflow Tract Ventricular Tachycardia Structural Heart Disease

21 Outflow Tract Ventricular Tachycardia 48 y old male, presented with sustained VT I II III avr avl avf V1 V2 V3 V4 V5 V6

22 It is important to distinguish an idiopathic OTVT from a VT caused by structural heart diseases. I II III avr avl avf V1 V2 V3 V4 V5 V6

23 Outflow Tract Ventricular Tachycardia Structural Heart Disease Male, 62 years old; DM, HTN, 2001 Heart failure; EF: 41%; ICD Implantation 2008 due to MMVT; February 2010 admitted with incessant MMVT; EF: 35% SCA: Normal CA

24 Outflow Ventricular Tachycardia QRS Morphology during Ablation I II III avr avl avf V1 V2 V3 V4 V5 V6

25 Outflow Ventricular Tachycardia Dilated Cardiomyopathy

26 Outflow Ventricular Tachycardia I II III avr avl avf V1 V2 V3 V4 V5 V6

27 Outflow Tract Ventricular Tachycardia Structural Heart Disease Male, 60 years old; AVR and CABG 1 month before Admission Tachycardia was noticed at Rehabilitation Center EF: 65% SCA: all grafts were open The patient admitted for catheter ablation

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29 Outflow Tract Ventricular Tachycardia NO! Always Benign? A small group of patients with idiopathic OTVT could be classified as Malignant OTVT. In these patients more malignant ventricular arrhythmias (VF/PMVT), are occasionally initiated by OTVT or OT-VPC. All patients presenting with OT-VA require an evaluation for organic heart diseases (ARVC/D ) or genetic syndromes (BS, LQTS, CPVT) associated with sudden death.

30 Thank you!