Published Online
on September 10, 2009

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Request Permissions Google Scholar Articles by Steven, D. Articles by Stevenson, W. G. PubMed Articles by Steven, D. Articles by Stevenson, W. G. Related Collections Arrhythmias, clinical electrophysiology, drugs Ablation/ICD/surgery Coronary circulation

Original Article

Ventricular Tachycardia Arising from the Aortomitral Continuity in Structural Heart Disease: Characteristics and Therapeutical Considerations for an Anatomically Challenging Area of Origin

Daniel Steven¹; Kurt C. Roberts–Thomson; Jens Seiler; Keichii Inada; Usha B. Tedrow; Richard N. Mitchell; Piotr S. Sobieszczyk; Andrew C. Eisenhauer; Gregory S. Couper and William G. Stevenson

Brigham and Women's Hospital, Harvard Medical School, Boston, MA

^* Corresponding author; email: dsteven{at}uke.uni-hamburg.de

Background—The aortomitral continuity (AMC) has been described as a site of origin for ventricular tachycardias (VT) in structurally normal hearts. There is a paucity of data on the contribution of this region to VTs in patients with structural heart disease.

Methods and Results—Data from 550 consecutive patients undergoing catheter ablation for VT associated with structural heart disease were reviewed. Twenty-one (3.8%) had a VT involving the peri-AMC region (age 62.7 ± 11 years, median left ventricular ejection fraction 43.6 ± 17%). Structural heart disease was ischemic in 7 (33%), dilated cardiomyopathy in 10 (47.6%) and valvular cardiomyopathy in 4 (19%) patients, respectively. After 1.9 ± 0.8 catheter ablation procedures (including 3 transcoronary ethanol ablations) the peri-AMC VT was not inducible in 19 patients. The remaining two patients underwent cryosurgical ablation. Our first catheter ablation procedure was less often successful (66.7%) for peri-AMC VTs as compared to that for 246 VTs originating from the LV free wall (81.4%, p= 0.03). During a mean follow up of 1.9 ± 2.1 years, 12 (57.1%) patients remained free of VT, peri-AMC VT recurred in 7 patients and one patient had recurrent VT from a remote location. Three patients died. Analysis of 50 normal coronary angiograms demonstrated an early septal branch supplying the peri-AMC area in 58% of cases that is a potential target for ethanol ablation.

Conclusions—VTs involving the peri-AMC region occur in patients with structural heart disease and appear to be more difficult to ablate compared to VTs originating from the free LV wall. This region provides unique challenges for RF ablation, but cryosurgery and transcoronary alcohol ablation appear feasible in some cases.

Key Words: ablation • alcohol • angiography • catheter ablation • tachyarrhythmias