Idiopathic fascicular left ventricular tachycardia: linear ablation lesion strategy for noninducible or nonsustained tachycardia.
BACKGROUND
Idiopathic "fascicular" left ventricular tachycardia (IFLVT) is frequently not inducible or nonsustained at the time of planned catheter ablation. The mechanism of the arrhythmia has been suggested to be reentry involving a sizable area of the LV inferior septum extending from base toward the apex.


OBJECTIVE
We tested the ability of a series of radiofrequency lesions delivered in a linear fashion to the inferior-mid septum to control ventricular tachycardia not amenable to standard mapping ablation strategies.


METHODS
Programmed stimulation both at baseline state and with isoproterenol after heart rate was increased by at least 25% was performed in all patients. The patients included in the study were either non-inducible or only had brief nonsustained VT not amenable to "traditional" mapping. A detailed electroanatomic map of the LV was performed in sinus rhythm. The location of the linear lesion along the inferior septum was guided by the presence of Purkinje potentials, with pacemapping as an additional guide. A linear lesion was placed perpendicular to the long axis of the ventricle approximately midway from the base to the apex in the region of the mid to mid-inferior septum. Radiofrequency lesions were delivered using a 4mm tip catheter at 50 Watts and 52 degrees for 60-90 seconds.


RESULTS
Of 122 consecutive patients who underwent ablation of idiopathic VT from 1999 to 2003, 15 had IFLVT based on standard diagnostic criteria. Six of the 15 patients (40%) had nonsustained or no inducible VT in the EP lab. The number of RF lesions ranged from 7 to 15 (mean 9). The length of the effective linear lesion ranged from 1.2 to 2.2 cm (mean 1.7 cm). Development of left posterior fascicular block was noted in two of the six patients. However, despite the absence of development of left posterior fascicular block in the other four patients, no VT or premature ventricular beats could be induced after ablation using the same provocation maneuvers as performed in the baseline state. No spontaneous arrhythmias occurred during follow-up to 16 +/- 8 months (range 6 to 30 months).


CONCLUSIONS
In patients with difficult to induce or nonsustained VT with the typical right bundle branch block pattern and a superiorly directed axis on 12-lead ECG, RF energy ablation delivered in a linear fashion approximately midway to two thirds toward the apex along the mid to inferior septum and perpendicular to the plane of the septum is safe and effective for VT control.
Lin
David
D
Hospital of the University of Pennsylvania, University of Pennsylvania Health Systems, Department of Medicine, Electrophysiology Section, Philadelphia, Pennsylvania 19104, USA. david.lin@uphs.upenn.edu
Hsia
Henry H
HH
Gerstenfeld
Edward P
EP
Dixit
Sanjay
S
Callans
David J
DJ
Nayak
Hemal
H
Russo
Andrea
A
Marchlinski
Francis E
FE
D000293:Adolescent; D000328:Adult; D017115:Catheter Ablation; D004562:Electrocardiography; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery; D006339:Heart Rate; D006352:Heart Ventricles / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D017180:Tachycardia, Ventricular / Q000503:physiopathology* / Q000601:surgery*; D016896:Treatment Outcome