63 Characterization of the right ventricular substrate participating in post-infarction ventricular tachycardia

• Published in: Heart (British Cardiac Society) Vol. 105; no. Suppl 7; p. A51
• Main Authors: Walsh, K, Shah, R, Khan, S, Supple, G, Garcia, F, Frankel, D, Lin, D, Kumareswaran, R, Hyman, M, Arkles, J, Deo, R, Zado, E, Riley, M, Schaller, R, Nazarian, S, Dixit, S, Epstein, A, Callans, DJ, Marchlinski, FE, Santangeli, P
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group LTD 01.10.2019
• Subjects: Cardiac arrhythmia; Morphology; Patients
• ISSN: 1355-6037; 1468-201X
• DOI: 10.1136/heartjnl-2019-ICS.63

BackgroundThe right ventricle (RV) is uncommonly implicated in post-infarction ventricular tachycardia (PIVT). The prevalence and features of RV substrate participating in PIVT are undefined.ObjectivesTo characterize critical RV substrate (CRVS) involvement in PIVT.MethodsWe retrospectively reviewed 1065 patients with PIVT undergoing catheter ablation at our center from 2000 to 2017. Cases with CRVS defined by conclusive demonstration of participation to PIVT with activation, entrainment and/or pace mapping during sinus rhythm were included.ResultsRV mapping due to suspected participation in PIVT was performed in 58/1065 patients (5.4%), age 65±11 years, 91% males, LVEF 30±13%, all with LBBB morphology VT. CRVS was identified in 26 patients (2.4%, 11 anterior infarcts, 13 inferior infarcts) (table 1) with: 1) critical components of the PIVT circuit defined with activation/entrainment mapping or VT termination with RV ablation (n=21), 2) presence of low-voltage abnormal electrograms with excellent pace-map for the targeted VT and non-inducibility following ablation (n=5). CRVS was most commonly located in the septum (77%) followed by the free wall (23%) (figure 1). An additional 14 patients had no demonstrated CRVS but underwent empirical RV septal ablation in the process of biventricular septal substrate modification. Non-inducibility of the targeted VT following CRVS ablation was achieved in 28/34 patients (82%, 4 patients not tested), with non-inducibility of any VT in 18/34 (53%).Abstract 63 Table 1Patient characteristics, infarct territory, VT morphology and mapping dataAbstract 63 Table 1 Patient characteristics, infarct territory, VT morphology and mapping data Patient # Age Gender(M/F) EF (%) Infarct territory CAD history Critical RV Substrate criteria Critical RV Substrate location VT morphology, CL 1 71 M 54 Inferior CABG Entrainment/Activation* RV basal septal LBLS, 300 ms 2 72 M 10 Anterior PCI-LM & LCX & CABG Entrainment/Activation Septal, RVOT LBLI, 330 ms 3 64 M 20 Anterior, inferior CABG Entrainment/Activation* RV Free wall LBLI, 300 ms 4 87 M 20 Inferior, apical CABG Entrainment/Activation* RV basal septal LBLS, 500 ms 5 50 M 30 Anterior PCI-LAD Entrainment/Activation RV apical septum LBLS, 390 ms 6 41 F 25 Anterior, apical CABG Entrainment/Activation* RV apical septum LBLS, 543 ms 7 29 M 25 Anterior, apical PCI-RCA Entrainment/Activation RV apical septum LBLS, 390 ms 8 62 M 15 Anterior CABG Substrate/Pacemapping RV mid septum LBLS, 345 ms 9 51 M 40 Inferior, apical PCI-RCA Entrainment/Activation* RV apical septum LBLS, 410 ms 10 47 M 45 Inferior, septal PCI-RCA Entrainment/Activation* RV basal inferoseptum LBLS, 550 ms 11 70 M 35 Posterior, lateral CABG Entrainment/Activation RV inferior septum LBLS, 370 ms 12 66 M 20 Inferior, lateral PCI-LCx & CABG Substrate/Pacemapping RVOT free wall LBLI, 440 ms 13 61 M 15 Anterior CABG Entrainment/Activation* RVOT free wall LBLI, 435 ms 14 68 M 30 Inferior PCI-RCA Substrate/Pacemapping inferior RV LBLS, 314 ms 15 53 M 45 Inferior PCI-RCA Entrainment/Activation basal inferoseptal RV LBLS, 300 ms 16 55 M 65 Inferior PCI-RCA & CABG Entrainment/Activation RVOT free wall LBLS, 450 ms 17 86 M 20 Anterior Medical management Entrainment/Activation* RV septal apex LBLS, 445 ms 18 70 M 33 Inferior Medical management Entrainment/Activation RV basal, inferior septum LBLS, 500 ms 19 80 M 15 Inferior Medical management Entrainment/Activation RV inferior, apical septum LBLS, 390 ms 20 60 M 30 Anterior, apical CABG Entrainment/Activation* RV apical septum LBLS, 543 ms 21 59 M 30 Anterior, apical CABG Entrainment/Activation RV apical septum LBLS, 520 ms 22 62 M 15 Inferior, lateral CABG Entrainment/Activation* RV inferoseptum LBLS, 700 ms 23 62 M 15 Inferior, lateral CABG Entrainment/Activation* RV inferoseptum basal LBLS, 560 ms 24 56 M 25 Anterior PCI LAD & RCA Entrainment/Activation* Anterior RVOT, epicardial LBRI, 450 ms 25 83 M 30 Inferior CABG Entrainment/Activation⌘ RV septum, just inferior to His position LBLS, 460 ms 26 76 M 50 Anteroseptal PCI LAD & LCX Substrate/Pacemapping RV free wall LBLI, 320 ms * Termination with RV ablation; ⌘ Presence of critical RV substrate but no RV ablation. Abstract 63 Figure 1Termination without global ventricular capture at the RV apical septum, VT termination within 5 seconds of RF application at that site (Patient #6) Termination without global ventricular capture at the RV apical septum, VT termination within 5 seconds of RF application at that site (Patient #6)ConclusionThe RV contains critical substrate elements of PIVT in at least 2.4% of cases, most commonly involving the RV septum.