Ablation of Ventricular Arrhythmias From the Left Ventricular Apex in Patients Without Ischemic Heart Disease

• Published in: JACC. Clinical electrophysiology 2020-09, Vol.6 (9), p.1089-1102
• Main Authors: Walsh, Katie A., Supple, Gregory E., Garcia, Fermin C., Frankel, David S., Lin, David, Kumareswaran, Ramanan, Hyman, Matthew, Arkles, Jeffrey S., Deo, Rajat, Riley, Michael P., Schaller, Robert D., Nazarian, Saman, Santangeli, Pasquale, Dixit, Sanjay, Epstein, Andrew E., Callans, David J., Marchlinski, Francis E.
• Format: Article
• Language: English
• Subjects: ablation; premature ventricular complexes; ventricular arrhythmia; ventricular tachycardia
• ISSN: 2405-500X; 2405-5018
• DOI: 10.1016/j.jacep.2020.04.021

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. 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. Patients referred for CA of VA at our institution were retrospectively reviewed, and those with LVA VA in the absence of CAD were identified. 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%). 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. [Display omitted]