Andrade JG, Verma A, Mitchell LB, et al; CCS Atrial Fibrillation Guidelines Committee. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2018 Nov;34(11):1371-1392. doi: 10.1016/j.cjca.2018.08.026. PubMed PMID: 30404743.
January CT, Wann LS, Alpert JS, et al; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):e199-267. doi: 10.1161/CIR.0000000000000041. Epub 2014 Mar 28. Erratum in: Circulation. 2014 Dec 2;130(23):e272-4. PubMed PMID: 24682347; PubMed Central PMCID: PMC4676081.
Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013. Heart Rhythm. 2013 Dec;10(12):1932-63. doi: 10.1016/j.hrthm.2013.05.014. Epub 2013 Aug 30. Review. PubMed PMID: 24011539.
Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013 Aug;34(29):2281-329. doi: 10.1093/eurheartj/eht150. Epub 2013 Jun 24. PubMed PMID: 23801822.
American College of Cardiology Foundation; American Heart Association; European Society of Cardiology; Heart Rhythm Society, Wann LS, Curtis AB, Ellenbogen KA, et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2013 May 7;127(18):1916-26. doi: 10.1161/CIR.0b013e318290826d. Epub 2013 Apr 1. PubMed PMID: 23545139.
Camm AJ, Lip GY, De Caterina R, et al; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012 Nov;33(21):2719-47. doi: 10.1093/eurheartj/ehs253. Epub 2012 Aug 24. Erratum in: Eur Heart J. 2013 Mar;34(10):790. Eur Heart J. 2013 Sep;34(36):2850-1. PubMed PMID: 22922413.
Tracy CM, Epstein AE, Darbar D, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; Heart Rhythm Society. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. [corrected]. Circulation. 2012 Oct 2;126(14):1784-800. doi: 10.1161/CIR.0b013e3182618569. Epub 2012 Sep 10. Erratum in: Circulation. 2013 Jan 22;127(3):e357-9. Heart Rhythm Society [added]. PubMed PMID: 22965336.
Pediatric and Congenital Electrophysiology Society (PACES); Heart Rhythm Society (HRS); American College of Cardiology Foundation (ACCF); American Heart Association (AHA); American Academy of Pediatrics (AAP); Canadian Heart Rhythm Society (CHRS), Cohen MI, Triedman JK, Cannon BC, et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm. 2012 Jun;9(6):1006-24. doi: 10.1016/j.hrthm.2012.03.050. Epub 2012 May 10. PubMed PMID: 22579340.
European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010 Oct;31(19):2369-429. doi: 10.1093/eurheartj/ehq278. Epub 2010 Aug 29. Erratum in: Eur Heart J. 2011 May;32(9):1172. PubMed PMID: 20802247.
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: see Table 3.4-1.
Antiarrhythmic agents: see 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.