Case scenario of a patient with idiopathic ventricular Tachycardia (VT), followed by a topic review including diagnosis and management guidelines. It is defined as Monomorphic VT in patients without any structural heart disease or coronary disease”. Classified on the basis of site of origin broadly into three different categories i.e Outflow Tract VT, Annular VT, Fascicular VT

1. IDIOPATHIC
VENTRICULAR
TACHYCARDIA (VT)
Dr. Muhammad Usman Javed

2. Case:
 A 40 year old man without any comorbid
brought into the emergency room in a
collapsed state. Only carotid pulse was
palpable and blood pressure was 80/45
mmHG.

4. Findings suggestive of Idiopathic Posterior Fascicular VT
• wide-complex tachycardia(QRS duration=120msec) at a rate of 180 bpm
• RBBB pattern and left axis deviation

5.  DC Cardioversion, Intravenous amiodarone,
lidocaine and adenosine were tried but did not
terminate it.
 Finally, the patient received intravenous
Verapamil, which terminated the tachycardia
with resultant normal sinus rhythm.

6.  His coronary angiography was done which
showed normal coronaries
 discharged home with the plan to return for a
radiofrequency ablation.

7. Idiopathic VT
 “Monomorphic VT in patients without any
structural heart disease or coronary disease”
 Classified on the basis of site of origin
 Outflow Tract VT
 Annular VT
 Fascicular VT
Reference: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine

8.  Prognosis for all forms of idiopathic VT without
structural heart disease is good
 Amenable to ablation and respond well to drug
therapy
Reference: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine

9. 1. Outflow Tract Tachycardia
 RVOT VT (80%)
 Two types: Paroxysmal and Repetitive
monomorphic VT
 LVOT VT (10%)
 Proximal Pulmonary artery VT

10. Mechanism of Outflow tract VT
 is due to triggered activity
 Secondary to cyclic AMP mediated delayed after-
depolarisations (DADs)
 Example - Exertion results in increased cyclic
AMP due to beta receptor stimulation
 Release of calcium from sarcoplasmic reticulum
and DAD
 Mutations in signal transduction pathways
involving cAMP may be etiology for VT in some
patients

11. Typical ECG features:
 In RVOT VT:
 LBBB contour in V1
 Right axis
 In LVOT VT:
 Presence of S wave in lead I
 Early precordial R wave transition (V1 to V2)
Reference: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine

12. RVOT VT:
LBBB morphology in V1
Right axis

13. LVOT VT
LVOT VT:
Presence of S wave in lead I
Early precordial R wave transition (V1 to V2)

14. Outflow tract VT
 Terminated by:
 Vagal maneuvers
 Adenosine
 Beta blockers
 Calcium channel blockers

15. 2. Annular VT
 VTs arising from the mitral or tricuspid annulus
account for 4% to 7% of cases of idiopathic
VT.
 behave similarly to outflow tract VT, both in
prognosis and in drug response.

16. ECG features of annular VT
 Mitral annular VT
 typically a RBBB pattern (transition in V1 or V2),
 S wave in V6, and monophasic R or Rs in leads
V2 through V6.

17. RBBB pattern (transition in V1 or V2),
S wave in V6

18. 3. Fascicular VT (Verapamil
sensitive VT)
 Usually occurs in young healthy patients (15-
40 years of age; 60-80% male).
 Most episodes occur at rest but may be
triggered by exercise, stress and beta
agonists.
 The mechanism is re-entrant tachycardia
due to an ectopic focus within the left ventricle.

19. ECG features of Fascicular VT
 QRS duration 100 – 140 ms
(this is narrower than other forms of VT)
 Short RS interval
(the RS interval is usually > 100 ms in other types
of VT)
 RBBB Pattern.
 Axis deviation depending on anatomical site of
re-entry circuit

20.  Posterior fascicular VT (90-95% of cases):
RBBB morphology + left axis deviation; arises
close to the left posterior fascicle.
 Anterior fascicular VT (5-10% of cases):
RBBB morphology + right axis deviation; arises
close to the left anterior fascicle.

21.  difficult to treat as it is often unresponsive to
adenosine, vagal maneuvers, and lignocaine.
 characteristically responds to Verapamil.
 Digoxin-induced fascicular VT is responsive to
Digoxin Immune Fab.

22.  Patients with moderate symptoms can be
treated with oral verapamil (120 to 480
mg/day).
Radiofrequency catheter ablation is an
appropriate management strategy for patients
with severe symptoms or those intolerant or
resistant to medical therapy

23. Anterior Fascicular VT – RBBB Morphology and rightward axis

24. Posterior Fascicular VT: RBBB morphology with Left axis deviation . Narrow-
complex capture beat

25. Summary
Reference:
Prof. Josep Brugada; How to recognise and manage idiopathic ventricular
tachycardia
An article from the e-journal of the ESC Council for Cardiology Practice
Vol.8,N°26 - 09 Mar 2010

26. THANK YOU
To practice ECGs visit
www.pacedheart.com
Mega collection of ECGs
& Presentations