Background-To gain insight into the pathogenesis of right ventricular(RV) cardiomyopathy and ventricular tachycardia(VT), we determined the clinical and electroanatomic characteristics and outcome of ablative therapy ...Background-To gain insight into the pathogenesis of right ventricular(RV) cardiomyopathy and ventricular tachycardia(VT), we determined the clinical and electroanatomic characteristics and outcome of ablative therapy in consecutive patients with(1) RV dilatation, (2) multiple left bundle-branch block(LBBB)-type VTs, and (3) an abnormal endocardial substrate defined by contiguous electrogram abnormalities. Methods and Results-All 21 patients had detailed RV bipolar electrogram voltage mapping. Eighteen patients had simultaneous left ventricular(LV) mapping, including all 4 patients with right bundle-branch block(RBBB) VT. VT was ablated in 19 patients by use of focal and/or linear lesions with irrigated-tip catheters in 10 of 19 patients. Eighteen patients were men, age 47±18 years, and none had a family history of RV dysplasia. RV volume was 223±89 cm3. Electrogram abnormalities extended from perivalvular tricuspid valves(5 patients), pulmonic valves (6 patients), or both valves (10 patients). Electrogram abnormalities always involved free wall, spared the apex, and included the septum in 15 patients (71%). The area of abnormality was 55±37 cm2 (range, 12 to 130 cm2) and represented 34±19%of the RV. In 52 of 66 LBBB VTs, the origin was from the RV perivalvular region. LV perivalvular low-voltage areas noted in 5 patientswere associated with a RBBB VT origin. No VT recurred after ablation in 17 patients(89%) during 27±22 months. Conclusions-In patients with RVcardiomyopathy and VT, (1) perivalvular electrogram abnormalities represent the commonly identified substrate and source of most VT, (2) LV perivalvular endocardial electrogram abnormalities and VT can occasionally be identified, and (3) aggressive ablative therapy provides long-term VT control.展开更多
Background-Identifying the septal versus lateral site of origin of ventricular tachycardia(VT) with a right bundle-branch block (RBBB)-type pattern and an R-S ratio >1 in lead V1 is difficult with the 12-lead ECG, ...Background-Identifying the septal versus lateral site of origin of ventricular tachycardia(VT) with a right bundle-branch block (RBBB)-type pattern and an R-S ratio >1 in lead V1 is difficult with the 12-lead ECG, especially in patients with prior apical infarction. Methods and Results-We prospectively evaluated 58 patients with VT. Sixteen patients had apical infarcts(group 1), 29 had nonapical infarcts (group 2), and 13 had no heart disease (group 3). QRS complex onset to activation at the right ventricular apex(stim-RVA) was measured during left ventricular(LV) apical septal and lateral pacing, and 47 RBBB-type VTs (QRS-RVA) were localized to the septal or lateral apex by using entrainment techniques. Pacing and VT site of origin were confirmed by electroanatomic mapping. The stim-RVA time was 59±16 ms for septal versus 187±24 ms for lateral sites in group 1, P< 0.001; 70±14 ms for septal versus 169±19 ms for lateral sites in group 2, P< 0.001; and 42±15 ms for septal versus 86±16 ms for lateral sites in group 3, P< 0.005. The QRS-RVA time was 50±13 ms for apical septal VTs versus 178±21 ms for lateral VTs in group 1, P< 0.001; 71±17 ms for apical septal versus 157±20 ms for lateral VTs in group 2, P< 0.001; and 32±12 ms for septal versus 71±16 ms for lateral VTs in group 3, P< 0.01. Conclusions-The QRS-RVA differs for the VT site of origin from the LV septal versus lateral apex. These data prove useful in rapidly regionalizing the VT site of origin with a V 1 R-S ratio >1, particularly in instances of an apical infarct, where surface ECG distinctions are less identifiable.展开更多
Background: We describe the findings on esophagography, the frequency and appearance of leaks after laparoscopic Heller myotomy and fundoplication, and the utility of early postoperative studies for predicting clinica...Background: We describe the findings on esophagography, the frequency and appearance of leaks after laparoscopic Heller myotomy and fundoplication, and the utility of early postoperative studies for predicting clinical outcome. Methods: Our study group consisted of 40 patients who underwent laparoscopic Heller myotomy and fundoplication in whom radiographic studies were performed during the early postoperative period. The radiographic reports and images were reviewed to determine the esophageal diameter, visualization or nonvisualization of the wrap, and the presence or absence of a leak. The esophageal diameter subsequently was correlated with the clinical findings to determine whether this was a useful para meter for predicting clinical outcome. Results: Two patients (5%) had small, sealed off leaks on radiographic studies, and four (10%)had pseudo leaks result ing from trapping of contrast material alongside the fundoplication wrap. Twelve (60%) of 20 patients with adilated esophagus had esophageal symptoms on short term follow up versus three (15%) of 20 with a normal caliber esophagus (p = 0.008), and five (56%) of nine patients with a dilated esophagus had symptoms o n long term follow up versus six (43%) of 14 with a normal caliber esophagus (p = 0.68). Conclusion: Radiographic studies are useful for showing leaks after laparoscopic Heller myotomy and fundoplication, but radiologists should differe ntiate true leaks from trapping of contrast material alongside the fundoplication wrap. The caliber of the esophagus on early postoperative studies is also a us eful parameter for predicting short term clinical outcome in these patients.展开更多
文摘Background-To gain insight into the pathogenesis of right ventricular(RV) cardiomyopathy and ventricular tachycardia(VT), we determined the clinical and electroanatomic characteristics and outcome of ablative therapy in consecutive patients with(1) RV dilatation, (2) multiple left bundle-branch block(LBBB)-type VTs, and (3) an abnormal endocardial substrate defined by contiguous electrogram abnormalities. Methods and Results-All 21 patients had detailed RV bipolar electrogram voltage mapping. Eighteen patients had simultaneous left ventricular(LV) mapping, including all 4 patients with right bundle-branch block(RBBB) VT. VT was ablated in 19 patients by use of focal and/or linear lesions with irrigated-tip catheters in 10 of 19 patients. Eighteen patients were men, age 47±18 years, and none had a family history of RV dysplasia. RV volume was 223±89 cm3. Electrogram abnormalities extended from perivalvular tricuspid valves(5 patients), pulmonic valves (6 patients), or both valves (10 patients). Electrogram abnormalities always involved free wall, spared the apex, and included the septum in 15 patients (71%). The area of abnormality was 55±37 cm2 (range, 12 to 130 cm2) and represented 34±19%of the RV. In 52 of 66 LBBB VTs, the origin was from the RV perivalvular region. LV perivalvular low-voltage areas noted in 5 patientswere associated with a RBBB VT origin. No VT recurred after ablation in 17 patients(89%) during 27±22 months. Conclusions-In patients with RVcardiomyopathy and VT, (1) perivalvular electrogram abnormalities represent the commonly identified substrate and source of most VT, (2) LV perivalvular endocardial electrogram abnormalities and VT can occasionally be identified, and (3) aggressive ablative therapy provides long-term VT control.
文摘Background-Identifying the septal versus lateral site of origin of ventricular tachycardia(VT) with a right bundle-branch block (RBBB)-type pattern and an R-S ratio >1 in lead V1 is difficult with the 12-lead ECG, especially in patients with prior apical infarction. Methods and Results-We prospectively evaluated 58 patients with VT. Sixteen patients had apical infarcts(group 1), 29 had nonapical infarcts (group 2), and 13 had no heart disease (group 3). QRS complex onset to activation at the right ventricular apex(stim-RVA) was measured during left ventricular(LV) apical septal and lateral pacing, and 47 RBBB-type VTs (QRS-RVA) were localized to the septal or lateral apex by using entrainment techniques. Pacing and VT site of origin were confirmed by electroanatomic mapping. The stim-RVA time was 59±16 ms for septal versus 187±24 ms for lateral sites in group 1, P< 0.001; 70±14 ms for septal versus 169±19 ms for lateral sites in group 2, P< 0.001; and 42±15 ms for septal versus 86±16 ms for lateral sites in group 3, P< 0.005. The QRS-RVA time was 50±13 ms for apical septal VTs versus 178±21 ms for lateral VTs in group 1, P< 0.001; 71±17 ms for apical septal versus 157±20 ms for lateral VTs in group 2, P< 0.001; and 32±12 ms for septal versus 71±16 ms for lateral VTs in group 3, P< 0.01. Conclusions-The QRS-RVA differs for the VT site of origin from the LV septal versus lateral apex. These data prove useful in rapidly regionalizing the VT site of origin with a V 1 R-S ratio >1, particularly in instances of an apical infarct, where surface ECG distinctions are less identifiable.
文摘Background: We describe the findings on esophagography, the frequency and appearance of leaks after laparoscopic Heller myotomy and fundoplication, and the utility of early postoperative studies for predicting clinical outcome. Methods: Our study group consisted of 40 patients who underwent laparoscopic Heller myotomy and fundoplication in whom radiographic studies were performed during the early postoperative period. The radiographic reports and images were reviewed to determine the esophageal diameter, visualization or nonvisualization of the wrap, and the presence or absence of a leak. The esophageal diameter subsequently was correlated with the clinical findings to determine whether this was a useful para meter for predicting clinical outcome. Results: Two patients (5%) had small, sealed off leaks on radiographic studies, and four (10%)had pseudo leaks result ing from trapping of contrast material alongside the fundoplication wrap. Twelve (60%) of 20 patients with adilated esophagus had esophageal symptoms on short term follow up versus three (15%) of 20 with a normal caliber esophagus (p = 0.008), and five (56%) of nine patients with a dilated esophagus had symptoms o n long term follow up versus six (43%) of 14 with a normal caliber esophagus (p = 0.68). Conclusion: Radiographic studies are useful for showing leaks after laparoscopic Heller myotomy and fundoplication, but radiologists should differe ntiate true leaks from trapping of contrast material alongside the fundoplication wrap. The caliber of the esophagus on early postoperative studies is also a us eful parameter for predicting short term clinical outcome in these patients.
