Non-Scar-Related and Purkinje-Related Ventricular Tachycardia in Patients With Structural Heart Disease: Prevalence, Mapping Features, and Clinical Outcomes

• Published in: JACC. Clinical electrophysiology Vol. 6; no. 2; pp. 231 - 240
• Main Authors: Shirai, Yasuhiro, Liang, Jackson J, Hirao, Kenzo, Hyman, Matthew C, Kumareswaran, Ramanan, Arkles, Jeffrey S, Schaller, Robert D, Supple, Gregory E, Frankel, David S, Nazarian, Saman, Riley, Michael P, Garcia, Fermin C, Lin, David, Dixit, Sanjay, Callans, David J, Marchlinski, Francis E, Santangeli, Pasquale
• Format: Journal Article
• Language: English
• Published: United States 01.02.2020
• Subjects: Aged; Cardiomyopathies - complications; Catheter Ablation; Cicatrix - physiopathology; Female; Humans; Male; Middle Aged; Prevalence; Purkinje Fibers - physiopathology; Retrospective Studies; Tachycardia, Ventricular - classification; Tachycardia, Ventricular - complications; Tachycardia, Ventricular - epidemiology; Tachycardia, Ventricular - surgery; ventricular tachycardia; catheter ablation; structural heart disease
• ISSN: 2405-5018
• DOI: 10.1016/j.jacep.2019.09.014

This study sought to evaluate the prevalence, mapping features, and ablation outcomes of non-scar-related ventricular tachycardia (NonScar-VT) and Purkinje-related VT (Purkinje-VT) in patients with structural heart disease. VT in structural heart disease is typically associated with scar-related myocardial re-entry. NonScar-VTs arising from areas of normal myocardium or Purkinje-VTs originating from the conduction system are less common. We retrospectively analyzed 690 patients with structural heart disease who underwent VT ablation between 2013 and 2017. A total of 37 (5.4%) patients (16 [43%] with ischemic cardiomyopathy, 16 [43%] with nonischemic dilated cardiomyopathy, and 5 [14%] others) demonstrated NonScar/Purkinje-VTs, which represented the clinical VT in 76% of cases. Among the 37 VTs, 31 (84%) were Purkinje-VTs (28 bundle branch re-entrant VT). The remaining 6 (16%) VTs were NonScar-VTs and included 4 idiopathic outflow tract VTs. A total of 16 patients had prior history of VT ablations: empirical scar substrate modification was performed in 6 (38%) patients and residual inducibility of VT had not been assessed in 7 (44%). In all 37 patients, the NonScar/Purkinje-VT was successfully ablated. After a median follow-up of 18 months, the targeted NonScar/Purkinje-VT did not recur in any patients, and 28 (76%) of patients were free from any recurrent VT episodes. NonScar/Purkinje-VTs can be identified in 5.4% of patients undergoing VT ablation in the setting of structural heart disease. Careful effort to induce, characterize, and map these VTs is important because substrate-based ablation strategies would fail to eliminate these types of VT.