Clinical introduction A 52-year-old woman with shortness of breath and palpitations was referred to a cardiologist. A 24-hour Holter demonstrated high density (37%) of ventricular premature beats (VPBs) and long runs of non-sustained (eventually sustained) monomorphic ventricular tachycardia (VT) with the same morphology as several VPBs detected in a 12-lead ECG (figure 1A). A transthoracic echocardiogram was performed, and the patient’s evaluation was completed with a functional and gadolinium-enhanced cardiovascular MR (CMR) study (figure 1B,C) to assess structural heart disease. In a follow-up visit, an electrophysiological study (EPS) was performed to identify the origin of VPBs and VT (figure 1D).

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

(A) A 12-lead ECG. (B) Cine CMR-SSFP (steady-state-free-precession) sequence on a three-chamber view. (C) Inversion-recovery gradient echo CMR pulse sequence for delayed enhancement assessment. (D) Three-dimensional electroanatomic voltage mapping of the left ventricular cavity (cranial left anterior oblique view). CMR, cardiovascular MR.

Question What is the most likely cause of VPBs and VT?

1. Idiopathic VT in the absence of structural heart disease.

2. Bileaflet mitral valve prolapse (MVP).

3. Dilated cardiomyopathy.

4. Left ventricular non-compaction cardiomyopathy.

5. Ischaemic cardiomyopathy.

Question