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Definition, Etiology, PathogenesisTop
Idiopathic ventricular tachycardias (VTs) include 2 types of focal arrhythmias: outflow tract VT and fascicular VT (left septal VT) in patients without structural heart disease. These arrhythmias are idiopathic and generally associated with a good prognosis. They may present as frequent premature ventricular contractions (PVCs) or episodes of sustained VT.
Clinical Features and Natural HistoryTop
Symptoms range from none (asymptomatic) to paroxysmal palpitations. Symptom severity depends on the hemodynamic significance of the arrhythmia. Patients with very frequent PVCs (>30% of total beats in 24 hours) may develop cardiomyopathy. Symptoms are frequently exacerbated by stress or exercise.
1) Outflow tract VT: The most common type, either in the form of monomorphic PVCs or monomorphic VT. The hallmark is an inferior axis on ECG (positive QRS in the inferior leads; Figure 3.4-11).
2) Fascicular VT: The most common origin is the left posterior fascicle of the left bundle branch. ECG during tachycardia reveals a slightly widened QRS (usually <140 milliseconds, not as wide as in other VTs) with right bundle branch block (RBBB) and a left axis deviation (negative QRS in the inferior leads).
Differential diagnosis should include other types of VT or supraventricular tachycardia with aberrancy. It is important to exclude structural heart disease and to analyze QRS morphology during the arrhythmia. VT in arrhythmogenic right ventricular cardiomyopathy can resemble benign right outflow tachycardia; determination of the nature of ventricular arrhythmia in this case is an evolving field requiring expert input.
Classification of antiarrhythmic drugs: Table 3.4-1.
Antiarrhythmic agents: Table 3.4-2.
1. Fascicular VT commonly responds to verapamil (IV or oral).
2. When outflow tract VT/PVCs are suspected, beta-blockers, diltiazem, or verapamil should be considered. This type of VT may also respond to class Ic antiarrhythmics.
3. Catheter ablation is indicated in patients with symptomatic right ventricular outflow tract VT or fascicular VT who do not respond to antiarrhythmic drugs, are not willing to take medications on a long-term basis, or cannot tolerate the drugs.
Figure 3.4-11. Episode of monomorphic right ventricular outflow tract tachycardia.