Prevalence of a shared isthmus in postinfarction patients with pleiomorphic, hemodynamically tolerated ventricular tachycardias

Introduction: Multiple forms of ventricular tachycardia (VT) after myocardial infarction may result from multiple reentrant circuits that share an isthmus or from separate reentrant circuits. The prevalence of a shared isthmus in patients with multiple hemodynamically tolerated VTs has not been determined. Methods and Results: Criteria for a shared isthmus consisted of (1) concealed entrainment of > 1 VT at a single pacing site; (2) concealed entrainment during VT and a perfect pace map of another VT at the same pacing site; or (3) concealed entrainment of VT of a given morphology that had at least two cycle lengths that varied by at least 100 msec. In a series of 19 patients (16 men and 3 women; age 65 ± 14 years, ejection fraction 0.25 ± 0.09) with 54 VTs (mean cycle length 494 ± 98 msec), there was evidence of a shared isthmus in 23 VTs (43%) at 11 sites in 9 patients. Concealed entrainment of two different VTs was observed at 4 of 11 sites. At 5 of 11 sites there was concealed entrainment of one VT and a perfect pace map of another VT. At the remaining 2 of 11 sites, there was concealed entrainment of a VT that had two different cycle lengths. Nineteen of the 23 VTs were ablated successfully with radiofrequency energy applications at 11 sites. Conclusion: In postinfarction patients with pleiomorphic, hemodynamically stable VT, a shared isthmus may be present in approximately 40% of VTs.