1. Circ Arrhythm Electrophysiol
Left-Sided Ablation of Ventricular Tachycardia in Adults With Repaired Tetralogy of FallotCLINICAL PERSPECTIVE
by Gijsbert F.L. Kapel, Tobias Reichlin, Adrianus P. Wijnmaalen, Usha B. Tedrow, Sebastiaan R.D. Piers, Martin J. Schalij, Mark G. Hazekamp, Monique R.M. Jongbloed, William G. Stevenson, and Katja Zeppenfeld
Circ Arrhythm Electrophysiol
Volume 7(5):
October 21, 2014
Copyright © American Heart Association, Inc. All rights reserved.

2. The previously described 4 anatomic isthmuses for ventricular tachycardia (VT) in repaired Tetralogy of Fallot (rTOF).4 Anatomic isthmus 1 is located between the tricuspid annulus (TA) and a right ventricular (RV) incision/RV outflow tract (RVOT) patch (A and B), and anatomic isthmus 2 is located between a RV incision and pulmonary valve (PV; B).
The previously described 4 anatomic isthmuses for ventricular tachycardia (VT) in repaired Tetralogy of Fallot (rTOF).4 Anatomic isthmus 1 is located between the tricuspid annulus (TA) and a right ventricular (RV) incision/RV outflow tract (RVOT) patch (A and B), and anatomic isthmus 2 is located between a RV incision and pulmonary valve (PV; B). Anatomic isthmus 3, located between the PV and ventricular septal defect (VSD) patch, and anatomic isthmus 4, located between the VSD patch and TA (C), are bordering on the septum. ccw indicates counter clockwise; and cw, clockwise.
Gijsbert F.L. Kapel et al. Circ Arrhythm Electrophysiol. 2014;7:
Copyright © American Heart Association, Inc. All rights reserved.

3. Mapping catheter position on fluoroscopy (case 1).
Mapping catheter position on fluoroscopy (case 1). Position of the mapping catheter in the right ventricle (RV) during angiography of the aorta in left anterior oblique (LAO; A) and right anterior oblique (RAO; B) views. Position of the mapping catheter in the left coronary cusp of the aorta during ventricular tachycardia termination in LAO (C) and RAO views (D).
Gijsbert F.L. Kapel et al. Circ Arrhythm Electrophysiol. 2014;7:
Copyright © American Heart Association, Inc. All rights reserved.

4. Twelve-lead ECGs (sweep speed 25 and 100 mm/s) of the induced septal ventricular tachycardias (VTs) in all 4 cases.
Twelve-lead ECGs (sweep speed 25 and 100 mm/s) of the induced septal ventricular tachycardias (VTs) in all 4 cases. In patients 1, 2 and 4, the critical re-entry site was located at anatomic isthmus 3 (isthmus between ventricular septal defect [VSD] patch and pulmonary valve [PV]). VT1 in patient 1 and VT1 in patient 4 demonstrated a clockwise (cw) activation of isthmus 3; note the QR in lead V1. On the contrary, VT2 in patient 1 and VT1 in patient 2 demonstrated a counter clockwise (ccw) activation of isthmus 3; note the late transition in precordial leads. In patient 3, the critical re-entry site of VT2 was located at anatomic isthmus 4 (isthmus between VSD patch and tricuspid annulus) and the VT demonstrated cw rotation through isthmus 4.
Gijsbert F.L. Kapel et al. Circ Arrhythm Electrophysiol. 2014;7:
Copyright © American Heart Association, Inc. All rights reserved.

5. Intraoperative view of pulmonary valve replacement by pulmonary homograft in a patient with repaired Tetralogy of Fallot.
Intraoperative view of pulmonary valve replacement by pulmonary homograft in a patient with repaired Tetralogy of Fallot. Left: A cranial (top) to caudal view. Right: A caudal to cranial view. The anterior suture line is marked with the dashed line in both pictures. At both panels the pulmonary homograft is held by the forceps. The pulmonary homograft is already posteriorly sutured to the ventricular septal defect patch (marked with *). After complete implantation of the homograft, important parts of the right ventricular (RV) outflow tract endocardium and in particular the infundibular septum are covered by the homograft. RA indicates right atrium; and VCS, vena cava superior.
Gijsbert F.L. Kapel et al. Circ Arrhythm Electrophysiol. 2014;7:
Copyright © American Heart Association, Inc. All rights reserved.

6. A, Electroanatomical activation map of the clinical ventricular tachycardia (VT; activation time color-coded according to bar) in left posterior and right lateral views.
A, Electroanatomical activation map of the clinical ventricular tachycardia (VT; activation time color-coded according to bar) in left posterior and right lateral views. Earliest right ventricular outflow tract (RVOT) activation was recorded at the anatomic isthmus between the pulmonary valve (PV) and ventricular septal defect (VSD) patch. Diastolic activity preceding RVOT activation by 30 ms could be recorded from the aortic root. B, From the aortic site, VT could be entrained with concealed fusion (postpacing interval [PPI]=VT cycle length [VTCL]=348 ms). Radiofrequency ablation at this side terminated VT <5 s. MAPd indicates bipolar recording of the distal mapping catheter; and RVa, right ventricular apex.
Gijsbert F.L. Kapel et al. Circ Arrhythm Electrophysiol. 2014;7:
Copyright © American Heart Association, Inc. All rights reserved.

7. Electroanatomical voltage map (voltage color-coded according to bar) of the right ventricle (RV) and coronary cusps in a modified right posterior view.
Electroanatomical voltage map (voltage color-coded according to bar) of the right ventricle (RV) and coronary cusps in a modified right posterior view. After failed ablation in RV, the aortic root was mapped (cusp anatomy visualized by intracardiac echo using CartoSound technology). During sinus rhythm, a late potential could be recorded between the noncoronary cusp (NCC) and right coronary cusp (RCC), and during ventricular tachycardia (VT), entrainment was consistent with an isthmus site. A single radiofrequency application terminated VT <10 s. LCA indicates left coronary artery; LCC, left coronary cusp; PV, pulmonary valve; and TV, tricuspid valve.
Gijsbert F.L. Kapel et al. Circ Arrhythm Electrophysiol. 2014;7:
Copyright © American Heart Association, Inc. All rights reserved.

8. Right ventricular (RV) view of a postmortem specimen with unrepaired Tetralogy of Fallot (4 years old).
Right ventricular (RV) view of a postmortem specimen with unrepaired Tetralogy of Fallot (4 years old). A, An overview. B to D, The relation between the aorta and outlet septum (*) in detail. The catheter (C) is positioned in the left coronary cusp. The catheter (D) is positioned at the pulmonary side of the outlet septum. Note the spatial relationship between the outlet septum and the sinus of the aorta (Ao). LV indicates left ventricle; RVOT, RV outflow tract; TV, tricuspid valve; and VSD, ventricular septal defect.
Gijsbert F.L. Kapel et al. Circ Arrhythm Electrophysiol. 2014;7:
Copyright © American Heart Association, Inc. All rights reserved.

9. Right ventricular (RV) view of a postmortem specimen with repaired Tetralogy of Fallot (24 years old).
Right ventricular (RV) view of a postmortem specimen with repaired Tetralogy of Fallot (24 years old). The correction consisted of infundibular resection and patch closure of a perimembranous ventricular septal defect (VSD). A1 and B1, An overview. A2 and B2, The infundibulum and VSD in detail. The prior location of the VSD patch (partly removed) is illustrated with the dashed circle in A2; the VSD patch is removed in B1 and B2. A probe was inserted in the pulmonary artery (not visible) and advanced through the pulmonary valve (not visible) into the infundibulum (visible). The probe is located on the pulmonary side of the outlet septum, that is, the isthmus between the VSD and pulmonary valve. B2, The outlet septum is marked by 2 dashed lines and perpendicular directed arrows. Note the thickness of the septum (9 mm) even after the correction. TV indicates tricuspid valve.
Gijsbert F.L. Kapel et al. Circ Arrhythm Electrophysiol. 2014;7:
Copyright © American Heart Association, Inc. All rights reserved.