Ventricular Tachycardia Around the Tricuspid Annulus in Right Ventricular Dysplasia
A 78-year-old man with palpitations, dizziness, and presyncope was referred to our institution for evaluation. He had first had symptoms at 46 years of age and received a single-chamber atrial pacemaker for suspected sick sinus syndrome.
A current angiogram showed an unremarkable left ventricle but a dilated right ventricular outflow tract and moderate dilatation of the right ventricular chamber. A diagnosis of right ventricular dysplasia was made, and the patient underwent an electrophysiological study to evaluate his palpitations and presyncope. During right ventricular stimulation, a sustained, hemodynamically stable, wide QRS complex tachycardia with a rate of 155 bpm could be reproducibly initiated (Figure 1⇓).
During tachycardia, endocardial mapping of the right and left ventricles was performed with a 3D electroanatomic mapping system (CARTO, Biosense Webster, Johnson & Johnson) to identify the reentry circuit before ablation.
A macroreentrant circuit located in the right ventricle was identified as the mechanism of the tachycardia. An area of slow conduction (speed of the electrical impulse, 0.55 m/s; Figure 2⇓, zigzag arrow) was found between the tricuspid annulus and an area of scar tissue within the posterolateral outflow tract of the right ventricle. Voltage mapping showed an area of low-amplitude potential within the area of slow conduction (Figure 3⇓, left). A linear radiofrequency lesion severing the anatomic isthmus between the tricuspid annulus and the scar area was created (Figure 3⇓, right), resulting in termination of the clinical arrhythmia. Ventricular tachycardia was not reinducible on repeated electrophysiological studies at 1 day and 1 week after ablation. At 6-month follow-up, the patient was clinically symptom-free.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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