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Localization of Ventricular Tachycardia Exit Site and Subsequent Contraction Sequence and Functional Effects With Bedside Radionuclide Angiography

Elias Botvinick, MD^_*,_*, Jesse Davis, MD^_*, Michael Dae, MD^_*, John O'Connell, BS^_*, Norberto Schechtmann, MD, Joseph Abbott, MD^_*, Fred Morady, MD, Peter Lanzer, MD, John Iskikian, MD, Melvin Scheinman, MD^_*

^_* Departments of Medicine and Radiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
University of Michigan Hospitals, Ann Arbor, Michigan
Drs. Schechtmann, Lanzer, and Iskikian are in private cardiology practices

^_* Reprint requests and correspondence: Dr. Elias H. Botvinick, Box 0214, University of California San Francisco, 505 Parnassus Avenue, San Francisco, California 94143 (Email: botvinicke{at}medicine.ucsf.edu).

Objectives: In an effort to better understand the clinical effects of ventricular tachycardia (VT), we sought to characterize function and conduction during VT in patients.

Background: The image evaluation of VT has been limited by the lack of technical tools and its often-dramatic hemodynamic effect. Objective bedside imaging of VT-induced changes in contraction pattern, synchrony, and volumes has never been performed but could aid in the understanding of rhythm tolerance.

Methods: Equilibrium radionuclide angiography (ERNA) with phase analysis was performed during the course of 32 VT rhythms. Left ventricular ejection fraction, wall motion, synchrony, relative volumes, and exit sites were compared in 13 patients tolerant to VT (Group I) and 9 intolerant to VT (Group II).

Results: The ERNA VT exit site agreed with the results of electrocardiogram in 26 of 32 (81%) cases and with electrophysiologic study in 16 of 19 (84%) cases (both p < 0.05). A greater rate (157 vs. 130, p < 0.0001) accompanied VT intolerance, but the exit site in 4 patients with multiple VT patterns also appeared important to tolerance. Left ventricular ejection fraction, similar in both groups in sinus rhythm, decreased with VT in Groups I (28 to 19) and II (31 to 15), both p<0.03, with a greater relative decrease in LV ejection fraction, LV stroke volume (65% vs. 45%, p < 0.01), cardiac output (30% vs. 2%), and LV end-diastolic volume (36% vs. 27%, both p < 0.001), in Group II. The standard deviation of LV phase angle (Ø) was the only parameter which differed between Groups I and II (35 vs. 45, p < 0.01) in sinus rhythm. With VT, wall motion deteriorated generally, but with greater standard deviation LVØ, p < 0.05, and dyssynchrony in Group II. Ventricular tachycardia induced 14 functional aneurysms, often adjacent to VT exit sites.

Conclusions: A challenging bedside imaging protocol evaluated VT-induced changes. We found that the use of ERNA demonstrated function, synchrony, and volume differences between tolerant and intolerant VT rhythms, delineated the contraction pattern, and localized exit sites.

Key Words: imaging • scintigraphy • electrophysiology

Abbreviations and Acronyms   CO = cardiac output   EDV = end-diastolic volume   EF = ejection fraction   ERNA = equilibrium radionuclide angiography   LAO = left anterior oblique   LV = left ventricular   RV = right ventricular   SV = stroke volume   VT = ventricular tachycardia

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