Korean Circ J.  2015 Nov;45(6):526-530. 10.4070/kcj.2015.45.6.526.

Intramural Reentrant Ventricular Tachycardia in a Patient with Severe Hypertensive Left Ventricular Hypertrophy

• Lin CY
• Chung FP
• Lin YJ
• Chen SA

• KMID: 2223793
• DOI: http://doi.org/10.4070/kcj.2015.45.6.526

Abstract

We describe the case of a patient with severe hypertensive left ventricular hypertrophy and sustained hemodynamically unstable ventricular tachycardia (VT). Entrainment was demonstrated in the electrophysiological study. Activation mapping and pacemapping identified the location of the intramural reentrant VT with the exit site close to the epicardium. However, VT persisted after ablation at the epicardial exit site. Successful ablation was performed endocardially at the corresponding position.

Keyword

Catheter ablation; Hypertension; Hypertrophy, left ventricular; Tachycardia, ventricular

MeSH Terms

Catheter Ablation
Humans
Hypertension
Hypertrophy, Left Ventricular*
Pericardium
Tachycardia, Ventricular*

Figure

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  Fig. 1 Electrocardiographic morphologies of ventricular arrhythmia and echocardiography in a patient with severe concentric left ventricular hypertrophy (LVH). (A) Ventricular tachycardia (VT) ECG demonstrates a right bundle branch block, positive precordial concordance, and inferior axis with the presence of a pseudo-delta wave, high maximum deflection index, q wave in lead I, suggesting the tachycardia originating from the basal lateral mitral area epicardially. Alternation of VT cycle length with variation of QRS morphologies is noted. (B) Echocardiography reveals severe concentric LVH (intraventricular septum at diastole/posterior wall at diastole: 17/18 mm); cardiac magnetic resonance imaging shows subendocardial late gadolinium enhancement in the posterior septum, posteroinferior wall (C, arrow) and basal lateral wall (D, arrow) of the LV. LV: left ventricle, ECG: electrocardiography.

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  Fig. 2 The voltage mapping (upper panel) and (Pace Mapping Software, PASO; Biosense Webster, Inc., Diamond Bar, CA, USA) mapping (lower panel) demonstrated the best pacemapping site at the epicardial basal lateral mitral annulus with globally normal voltage. The local electrograms of the irrigated tip catheter (Thermocool, Biosense Webster Inc., Diamond Bar, CA, USA) at the epicardium but not at the endocardium preceded the ventricular ectopy by 33 msec.

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  Fig. 3 Changing morphology during ventricular tachycardia. (A) Illustration demonstrates change in the ventricular tachycardia (VT) exit site from the epicardium to the endocardium and epicardial alterns after epicardial ablation. (B) Epicardial ablation results in variation of VT ECG morphology and cycle length. Presence of pseudo-delta waves (arrow) in the even beats but not in the odd bests suggest the VT exit to the epicardium and endocardium alternatively. ECG: electrocardiography.

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