Published Online
on October 29, 2007

A more recent version of this article appeared on November 13, 2007

This Article Full Text (PDF) All Versions of this Article: 116/20/2241    most recent CIRCULATIONAHA.107.723551v1 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 Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zeppenfeld, K. Articles by Stevenson, W. G. Search for Related Content PubMed PubMed Citation Articles by Zeppenfeld, K. Articles by Stevenson, W. G. Related Collections Ablation/ICD/surgery Arrhythmias, clinical electrophysiology, drugs

Submitted on June 25, 2007
Accepted on August 22, 2007

Catheter Ablation of Ventricular Tachycardia After Repair of Congenital Heart Disease. Electroanatomic Identification of the Critical Right Ventricular Isthmus

Katja Zeppenfeld MD^*, Martin J. Schalij MD, Margot M. Bartelings MD, Usha B. Tedrow MD, Bruce A. Koplan MD, Kyoko Soejima MD, and William G. Stevenson MD

From the Departments of Cardiology and Anatomy, Leiden University Medical Center, Leiden, the Netherlands (K.Z., M.J.S., M.M.B.), and the Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass (U.B.T., B.A.K., K.S., W.G.S.).

^* To whom correspondence should be addressed. E-mail: k.zeppenfeld{at}lumc.nl.

Background—Catheter ablation of ventricular tachycardia (VT) after repair of congenital heart disease can be difficult because of nonmappable VTs and complex anatomy. Insights into the relation between anatomic isthmuses identified by delineating unexcitable tissue using substrate mapping techniques and critical reentry circuit isthmuses might facilitate ablation.

Methods and Results—Sinus rhythm voltage mapping of the right ventricle was performed in 11 patients with sustained VT after repair of congenital heart disease. Unexcitable tissue from patch material, valve annulus, or dense fibrosis, identified from bipolar voltage (<0.5 mV) and pacing threshold (>10 mA), was defined as an anatomic isthmus boundary bordering 4 isthmuses between (1) the tricuspid annulus and scar/patch in the anterior right ventricular outflow, (2) the pulmonary annulus and right ventricular free wall scar/patch, (3) the pulmonary annulus and septal scar/patch, and (4) the septal scar/patch and tricuspid annulus. The reentry circuit isthmuses of all induced 15 VTs (mean cycle length, 276±78 ms; 73% poorly tolerated), identified by activation, entrainment, and/or pace mapping, were located in an anatomic isthmus (11 of 15 VTs in anatomic isthmus 1). Transecting the anatomic isthmuses by ablation lesions abolished all VTs. During 30.4±29.3 months of follow-up, 91% of patients remained free of VT.

Conclusions—Reentry circuit isthmuses in VT late after repair of congenital heart disease are located within anatomically defined isthmuses bordered by unexcitable tissue. The boundaries can be identified with 3-dimensional substrate mapping and connected by ablation lines during sinus rhythm. These findings should facilitate catheter and surgical ablation of stable and unstable VTs.

Key words: catheter ablation • heart defects, congenital • tachyarrhythmias

This article has been cited by other articles:

				E. M. Aliot, W. G. Stevenson, J. M. Almendral-Garrote, F. Bogun, C. H. Calkins, E. Delacretaz, P. D. Bella, G. Hindricks, P. Jais, M. E. Josephson, et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA) Europace, June 1, 2009; 11(6): 771 - 817. [Full Text] [PDF]

				B. A. Koplan and W. G. Stevenson Ventricular Tachycardia and Sudden Cardiac Death Mayo Clin. Proc., March 1, 2009; 84(3): 289 - 297. [Abstract] [Full Text] [PDF]

				C. Knackstedt, P. Schauerte, and P. Kirchhof Electro-anatomic mapping systems in arrhythmias Europace, November 1, 2008; 10(suppl_3): iii28 - iii34. [Abstract] [Full Text] [PDF]

				F. Sacher, U. B. Tedrow, M. E. Field, J.-M. Raymond, B. A. Koplan, L. M. Epstein, and W. G. Stevenson Ventricular Tachycardia Ablation: Evolution of Patients and Procedures Over 8 Years Circ Arrhythm Electrophysiol, August 1, 2008; 1(3): 153 - 161. [Abstract] [Full Text] [PDF]

				G. F. Van Hare Substrate Mapping and Catheter Ablation of Ventricular Tachycardia after Right Ventriculotomy Circulation, November 13, 2007; 116(20): 2236 - 2237. [Full Text] [PDF]