Periaortic ventricular tachycardia in structural heart disease: Evidence of localized reentrant mechanisms

Heart Rhythm. 2020 Aug;17(8):1271-1279. doi: 10.1016/j.hrthm.2020.04.018. Epub 2020 Apr 21.


Background: The mechanisms for scar-related ventricular tachycardia (VT) originating from the periaortic region remain incompletely characterized.

Objective: The purpose of this study was to map the circuits responsible for periaortic VT in high resolution.

Methods: Cases with periaortic VT (2016-2020) were analyzed to characterize the substrate and mechanisms with multielectrode mapping. Periaortic VT was defined as low-voltage and/or deceleration zones within 2 cm of the left ventriculoaortic junction with a corresponding critical site during VT.

Results: Forty-nine periaortic monomorphic VTs were analyzed in 30 patients (25% of all patients with nonischemic cardiomyopathy). Isolated periaortic substrate was observed in 27% of patients, with 73% having concomitant scar, most commonly in the mid-septum (47%). Deceleration zones were equally prevalent on the septal and lateral portions of the periaortic region (87% vs 73%; P = .19). During activation mapping of VT (tachycardia cycle length 392 ± 105 ms), localized reentrant patterns of activation (14 mm [10-17 mm] × 10 mm [7-14 mm]) were demonstrated in 63% and 37% of VTs showed centrifugal activation, consistent with a focal breakout pattern. Ninety-three percent of VTs fulfilled criteria for a reentrant mechanism. Sixty-five percent of reentrant circuits had endocardial activation gaps within the tachycardia cycle length (3-dimensional circuitry), which were associated with higher rates of recurrence as compared with 2-dimensional complete circuits at 1 year (73% vs 37%; P = .028).

Conclusion: Periaortic VTs were observed in 25% of patients with nonischemic cardiomyopathy and scar-related VT. For the first time, localized reentry confined to this anatomically challenging region was demonstrated as the predominant mechanism by high-resolution circuit activation mapping.

Keywords: Catheter ablation; High-resolution mapping; Periaortic VT; Reentry.

MeSH terms

  • Aged
  • Catheter Ablation / methods
  • Cicatrix / complications*
  • Cicatrix / physiopathology
  • Electrophysiologic Techniques, Cardiac
  • Female
  • Follow-Up Studies
  • Heart Conduction System / physiopathology*
  • Heart Ventricles / physiopathology*
  • Humans
  • Male
  • Middle Aged
  • Prospective Studies
  • Tachycardia, Ventricular / etiology
  • Tachycardia, Ventricular / physiopathology*
  • Tachycardia, Ventricular / surgery