Published Online
on May 12, 2003

A more recent version of this article appeared on June 3, 2003

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Submitted on December 16, 2002
Revised on February 27, 2003
Accepted on March 2, 2003

An Underrecognized Subepicardial Reentrant Ventricular Tachycardia Attributable to Left Ventricular Aneurysm in Patients With Normal Coronary Angiogram

Feifan Ouyang MD^*, Matthias Antz MD, Florian T. Deger MD, Dietmar Bänsch MD, Anselm Schaumann MD, Sabine Ernst MD, and Karl-Heinz Kuck MD

From the II. Med. Abteilung, Allgemeines Krankenhaus St Georg, Hamburg, Germany.

^* To whom correspondence should be addressed. E-mail: Ouyangfeifan{at}aol.com.

Background--In patients with apparently normal hearts, ventricular tachycardia (VT) may only involve the subepicardial myocardium.

Methods and Results--Four patients with exercise-induced fast VT with right bundle branch block morphology were investigated. ECG showed a small q wave in leads II, III, and aVF during sinus rhythm (SR) in all 4 patients. Left ventricular angiography showed small inferolateral aneurysms in all patients. Coronary angiogram was normal in all 4 patients. Six unstable VTs (cycle length, 200 to 305 ms) and 1 stable VT (cycle length 370 ms) were reproducibly induced in the 4 patients. During SR, endocardial mapping was normal in all 4 patients, and epicardial mapping showed fragmented and late potentials in the left inferolateral wall anatomically consistent with the left ventricle aneurysm. During tachycardia, epicardial mapping showed a macroreentrant VT with focal endocardial activation in the patient with stable VT, whereas in 2 patients with unstable VT, a diastolic potential was only recorded and coincided with the late potential in the same area. Epicardial ablation was performed in 3 patients and successfully abolished those VTs. No VT recurred in 2 patients during follow-up of 2 and 9 months. Clinical VT recurred 6 months after the ablation and was successfully ablated in a repeated epicardial ablation in 1 patient. In the remaining patient without epicardial ablation, an implantable cardiac defibrillator was implanted. There were multiple shocks during a follow-up of 31 months.

Conclusions--In patients with normal coronary angiogram and left ventricle aneurysm, exercise-induced VT with right bundle branch block morphology may have a subepicardial arrhythmogenic substrate, which may be amenable to epicardial ablation.

Key words: cardiomyopathy • mapping • syncope • tachycardia

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