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Circulation, Vol 84, 1058-1071, Copyright © 1991 by American Heart Association
W Kaltenbrunner, R Cardinal, M Dubuc, M Shenasa, R Nadeau, G Tremblay, M Vermeulen, P Savard and PL Page
BACKGROUND. Left ventricular endocardial reentry is the conventional
concept underlying surgery for ventricular tachycardia (VT). We assessed
the incidences of patterns showing complete reentry circuits at either the
subendocardial or subepicardial level and of patterns in which left
ventricular endocardial mapping could only in part account for a reentrant
mechanism. METHODS AND RESULTS. We retrospectively analyzed epicardial and
left ventricular endocardial isochronal maps of 47 VTs induced in 28
patients with chronic myocardial infarction (inferior, 14 patients;
anteroseptal, 14 patients). Electrograms were recorded intraoperatively
from 128 sites with epicardial sock and transatrial left ventricular
endocardial balloon electrode arrays. Given the methodology used in this
study, the mapping characteristics of the tachycardias suggested five types
of activation patterns: 1) complete (90% or more of VT cycle length)
subendocardial reentry circuits in seven VTs (15%) and seven patients
(25%), 2) complete subepicardial reentry circuits in four VTs (9%) and four
patients (14%), 3) incompletely mapped circuits with a left ventricular
endocardial breakthrough preceding the epicardial breakthrough in 25 VTs
(53%) and 21 patients (75%), 4) incompletely mapped circuits with a left
ventricular epicardial breakthrough preceding the endocardial breakthrough
in three VTs (6%) and three patients (11%), and 5) a right ventricular
epicardial breakthrough preceding the left ventricular endocardial
breakthrough in eight VTs (17%) and seven patients (25%). After surgery,
one type 3 VT and three type 5 VTs were reinducible. Thus, left ventricular
endocardial reentry substrates (types 1 and 3) accounted for 68% of VTs,
but substrates involving subepicardial (types 2 and 4) and deep septal
layers (type 5) accounted for 32% of VTs. CONCLUSIONS: In a substantial
number of VTs, a substrate localization that is at variance with the
conventional concept can be detected by simultaneous epicardial and
endocardial mapping and may require modification of the surgical approach
conventionally aimed at endocardial layers.
ARTICLES
Epicardial and endocardial mapping of ventricular tachycardia in patients with myocardial infarction. Is the origin of the tachycardia always subendocardially localized?
Department of Medicine, Hopital du Sacre-Coeur, Universite de Montreal, Quebec, Canada.
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