Author + information
- Received December 6, 2019
- Revision received March 19, 2020
- Accepted April 15, 2020
- Published online May 27, 2020.
- Katie A. Walsh, MB BCh∗ (, )
- Gregory E. Supple, MD,
- Fermin C. Garcia, MD,
- David S. Frankel, MD,
- David Lin, MD,
- Ramanan Kumareswaran, MD,
- Matthew Hyman, MD, PhD,
- Jeffrey S. Arkles, MD,
- Rajat Deo, MD,
- Michael P. Riley, MD, PhD,
- Robert D. Schaller, DO,
- Saman Nazarian, MD, PhD,
- Pasquale Santangeli, MD, PhD,
- Sanjay Dixit, MD,
- Andrew E. Epstein, MD,
- David J. Callans, MD and
- Francis E. Marchlinski, MD
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- ↵∗Address for correspondence:
Dr. Katie A. Walsh, Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104.
Background The left ventricular apex (LVA) is a well-described source of ventricular arrhythmias (VAs) in patients with coronary artery disease (CAD) and history of apical infarction but is a rare source of VA in the absence of CAD.
Objectives This study aimed to characterize the incidence, clinical characteristics, and electrocardiographic and electrophysiologic features of LVA VA in the absence of CAD and to describe the experience with catheter ablation (CA) in this group.
Methods Patients referred for CA of VA at our institution were retrospectively reviewed, and those with LVA VA in the absence of CAD were identified.
Results Of 3,710 consecutive patients undergoing VA ablation, CA of LVA VA was performed in 24 patients (20 with monomorphic ventricular tachycardia, 4 with premature ventricular contractions or nonsustained ventricular tachycardia; 18 men; mean age: 54 ± 15 years). These cases comprised 10 of 35 (29%) hypertrophic cardiomyopathy, 9 of 789 (1.2%) nonischemic cardiomyopathy, and 5 of 1,432 (0.4%) idiopathic VA ablation procedures. VA QRS morphology was predominantly right bundle with slurred upstroke and right superior frontal plane axis with precordial transition ≤V3. Epicardial ablation was performed in 14 of 24 (58%). After a median of 1 procedure (range 1 to 4) at this institution and median follow-up of 47 months (range 0–176), VA recurred in 1 patient (4%).
Conclusions LVA VA in the absence of CAD is unusual and may occur in patients with hypertrophic cardiomyopathy or nonischemic cardiomyopathy or, rarely, in the absence of structural heart disease. It can be recognized by characteristic ECG features. CA of LVA VA is challenging; multiple procedures, including epicardial approaches, may be required to achieve VA control over long-term follow-up.
This work was supported by the Richard T. and Angela Clark Innovation Fund in Cardiovascular Medicine, the Mark Marchlinski EP Research & Education Fund, and the Winkelman Family Fund in Cardiovascular Innovation. Dr. Kumareswaran has served as an education consultant for Medtronic. Dr. Nazarian has served as a consultant to Circle Software, CardioSolv, Biosense Webster, and Siemens and has received research grants from ImriCor, Biosense Webster, and Siemens. Dr. Santangeli reports relationships with Abbott and Biosense Webster. Dr. Marchlinski has served as a consultant for Abbot Medical, Biosense Webster, Biotronik, and Medtronic Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received December 6, 2019.
- Revision received March 19, 2020.
- Accepted April 15, 2020.
- 2020 American College of Cardiology Foundation
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