title: Outcomes of Catheter Ablation of Idiopathic Outflow Tract Ventricular Arrhythmias With an R Wave Pattern Break in Lead V2: A Distinct Clinical Entity.
abstract: BACKGROUND
  In outflow tract ventricular arrhythmias (OT-VAs), an abrupt loss of the R wave in lead V2 compared to V1 and V3 (pattern break in V2-PBV2) suggests an origin close to the anterior interventricular sulcus (anatomically opposite to lead V2) and adjacent to proximal coronaries. We studied the outcome of catheter ablation of OT-VAs with a PBV2.
  
  
  RESULTS
  Of 130 consecutive patients with idiopathic left bundle block morphology OT-VAs and transition ≤V4, 12 (9%) had PBV2. Outcomes in this group were compared to the remaining 118 patients. Patients with PBV2 were more likely to be younger (41 ± 18 vs. 50 ± 14 years, P = 0.0384) and women (11 [92%] vs. 70 [59%], P = 0.0302). The earliest activation was at the RVOT in seven, left coronary cusp (LCC) in one, anterior interventricular vein (AIV) in two and the epicardium in two. In five (42%) cases (earliest activation in the AIV in two, epicardium in two, and RVOT below the valve level in one), ablation was aborted due to proximity to the left anterior descending (LAD) coronary artery. After 36 ± 17 months and 1.3 ± 0.5 procedures, VAs elimination was achieved in 58% of patients with PBV2 compared to 89% of the reference population (P = 0.0125) with effective site in five of seven at the most anterior and leftward RVOT adjacent to the pulmonic valve (PV).
  
  
  CONCLUSIONS
  OT-VAs with PBV2 demonstrate a unique ECG pattern and challenging catheter ablation. Proximity to LAD precludes ablation in about half. Long-term VA suppression could be achieved in only 58% of cases most commonly when the earliest site is at the anterior and leftward RVOT just under the PV.
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Hayashi
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santangeli
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Rajeev K
authors.initials: RK
authors.lastname: Pathak
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Daniele
authors.initials: D
authors.lastname: Muser
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Jackson J
authors.initials: JJ
authors.lastname: Liang
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Castro
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Fermin C
authors.initials: FC
authors.lastname: Garcia
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Mathew D
authors.initials: MD
authors.lastname: Hutchinson
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Gregory E
authors.initials: GE
authors.lastname: Supple
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Frankel
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Riley
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: David
authors.initials: D
authors.lastname: Lin
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Robert D
authors.initials: RD
authors.lastname: Schaller
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Dixit
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Callans
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Erica S
authors.initials: ES
authors.lastname: Zado
authors.affiliation: Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Francis E
authors.initials: FE
authors.lastname: Marchlinski
mesh_terms: D000200:Action Potentials; D000328:Adult; D002037:Bundle-Branch Block / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects; D004562:Electrocardiography; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006339:Heart Rate; D006352:Heart Ventricles / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: anterior interventricular sulcus; catheter ablation; epicardial ablation; outflow tract arrhythmias; ventricular tachycardia