Focal mechanism of ventricular tachycardia in coronary artery disease

BackgroundRe-entry is the most common mechanism of sustained monomorphic ventricular tachycardia (VT) in patients with coronary artery disease and prior myocardial infarction (MI).ObjectiveThis study sought to report the electrophysiological properties of a series of patients with prior MI who underwent radiofrequency ablation (RFA) for VT originating instead from a focal source.MethodsThe electrophysiological properties of 46 patients with prior MI (male 89%, age 64.8 ± 10.2 years) who underwent RFA for sustained VT were studied. A total of 101 VTs were induced (92 [91%] macro–re-entrant VT and 9 [9%] focal VT).ResultsOne patient had adenosine-sensitive idiopathic focal VT. The focal VT group had a significantly shorter pre-systolic interval (electrogram to QRS) during VT compared with the macro–re-entrant VT group (36 ± 17 ms vs. 117 ± 67 ms, P = .001). The successful ablation sites in the focal VT group also had a significantly lower ratio (in percentage) of electrogram-QRS interval to diastolic interval (VT cycle length − QRS duration) during VT (14 ± 8%) as compared with macro–re-entrant VTs (48 ± 30%, P <.001). Focal VTs demonstrated an apparent point source of endocardial activation and could not be entrained, whereas 77% of macro–re-entrant VTs were entrained. Successful ablation sites for focal VT (success rate 100%) were predominantly in the basal half of the left ventricle (75%), whereas only 60% of macro–re-entrant VTs (success rate 90.7%) were basal (P = .01). However, the procedure time, VT cycle length, number of RFA applications required for success, and acute success results were not significantly different in these 2 groups.ConclusionA focal mechanism is present in up to 9% of VTs in patients with CAD and prior MI that are induced during electrophysiology study for RF ablation. Mechanistic distinction from more typical macro–re-entrant VT in this population is important because ablation site characteristics are very different.