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Ventricular arrhythmias in patients with bicuspid aortic valves
Michael Ghannam1, Boldizsar Kovacs1, Jackson Liang1
1Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
Insights
Patients with bicuspid aortic valves (BAV) frequently experience ventricular arrhythmias (VA) originating near the valve. Late gadolinium enhancement (LGE) on cardiac MRI is common and indicates scar tissue that can trigger these arrhythmias.
Area of Science:
- Cardiology
- Congenital Heart Disease
- Cardiac Electrophysiology
Background:
- Bicuspid aortic valve (BAV) is the most prevalent congenital heart defect.
- The prevalence and characteristics of ventricular arrhythmias (VA) in BAV patients are not well-defined.
Purpose of the Study:
- To characterize VAs in patients with BAV.
- To investigate the role of late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) in BAV patients with VAs.
Main Methods:
- Retrospective analysis of 19 BAV patients undergoing VA ablation.
- All patients underwent programmed ventricular stimulation and LGE-CMR (except one).
- VA mapping and ablation were performed.
Main Results:
- Frequent premature ventricular contractions (PVCs) and inducible ventricular tachycardia (VT) were observed.
- Late gadolinium enhancement (LGE) was present in 13 patients, with larger scar in those with inducible VT.
- VAs were frequently mapped to the perivalvular area, and ablation led to significant reduction in PVC burden and improved ejection fraction.
Conclusions:
- Ventricular arrhythmias in BAV patients often originate from the perivalvular region.
- LGE is common in these patients and correlates with inducible VT, suggesting it represents an arrhythmogenic substrate.
- Ventricular remodeling secondary to BAV may contribute to LGE and VA.
Introduction:
Bicuspid aortic valves (BAV) are the most common congenital heart defects and the extent of ventricular arrhythmias (VA) in patients with BAV is unclear. The objective of this study is to describe VAs and late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) in patients with BAV.
Methods:
A total of 19 patients with BAV (18 males, age: 58 ± 13 years) were referred for VA ablation procedures. Ten patients had BAVs at the time of ablation, nine patients had prior aortic valve replacement for a BAV. All but one patient had LGE-CMR and all patients underwent programmed ventricular stimulation at the time of the ablation.
Results:
Frequent PVCs were the targeted VAs in 17/19 patients and VT in 2/19 patients. Monomorphic ventricular tachycardia (VT) was inducible in 6 patients. A total of 15 VTs were inducible (2.5 ± 1.0 VTs per patient with a mean cycle length of 322 ± 83 msec). LGE was present in 13 patients. Patients with inducible VT had larger borderzone and core scar compared to non-inducible patients (7.8 ± 2.1 cm3 vs. 2.5 ± 3.1 cm3 and 5.1 ± 2.6 cm3 vs. 1.9 ± 3.0 cm3, p-value < .05 for both). PVCs and VTs were mapped to the periaortic valve area in 12 patients and 4 patients, respectively. The PVC burden was reduced from 27 ± 13 to 3 ± 6 (p < .001) and the ejection fraction improved from 49 ± 13% to 55 ± 9% (p = .005).
Conclusions:
VAs in patients with BAV often originate from the perivalvular area and patients often have LGE and inducible VT. LGE may be due to ventricular remodeling secondary to the presence of BAV and harbors the arrhythmogenic substrate for VT.
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