Electrocardiographic features of failed and recurrent right ventricular outflow tract catheter ablation of idiopathic ventricular arrhythmias

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The majority of idiopathic ventricular arrhythmias (VAs) with a left bundle branch block (LBBB) and an inferior axis QRS morphology in patients with structurally normal hearts frequently originate from the right ventricular outflow tract (RVOT).1 The manifestation of RVOT VAs can vary from the presence of frequent premature ventricular complexes (PVCs) to repetitive salvos, nonsustained ventricular tachycardia (VT), and incessant VTs,3 which could lead to various clinical symptoms including palpitation, dyspnea, atypical chest pain, and syncope.4 Although idiopathic RVOT VAs are often regarded as benign, triggers arising from the RVOT with a very short coupling interval could carry the risk of initiating ventricular fibrillation (VF) and sudden cardiac death (SCD).5
Despite that antiarrhythmic drugs therapies have played an important role on the initial management of RVOT VAs, radiofrequency catheter ablation (RFCA), by targeting the arrhythmogenic foci within RVOT, provides an alternative and potentially curative strategy for drug‐refractory cases.6 The advancement of electroanatomical mapping and ablation technology leads to high acute success rate around 80–90%, whereas variable recurrence and failure rates have been reported.6 Given the complexity of the anatomic structure surrounding RVOT, in patients with failed ablation within the RVOT, those VAs might be successfully eliminated by targeting the adjacent structures, such as the aortic cusps, the great cardiac vein/anterior interventricular vein (GCV/AIV) junction, and/or the subvalvular aspect of the LV endocardium. Currently, various electrocardiographic algorithms have been proposed to predict the origin of VAs based on the QRS morphology, which could facilitate and help in deciding clinical approaches before intracardiac mapping and ablation procedure.10 However, previous report demonstrated that despite targeting multiple nearby anatomic structures, certain VAs might not be amenable to endocardial and/or epicardial interventions.14 In the present study, we aimed to identify the electrocardiographic features of the failed and recurrent RVOT ablation of idiopathic outflow tract (OT) VAs with QRS morphology of LBBB, a precordial transition ≥V3 and inferior axis.
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