Bicuspid aortic valve supporting supravalvular “substrate” for multiple ventricular tachycardias

Introduction The great arteries are an important source of arrhythmias, including premature ventricular contractions, ventricular tachycardia (VT), atrial tachycardia, and accessory pathways. The source of ventricular arrhythmias is thought to be muscular fibers extending from the outflow tracts to a variable extent above the valves. Ventricular arrhythmias from the aortic cusps exhibit complex patterns of activation breakout attributed to preferential conduction along complex insulated myocardial fibers; complexity in regional anatomy also makes mapping and ablation challenging. We present a unique case of bicuspid aortic valve harboring the necessary “substrate” for multiple reentrant VTs above and below the aortic valve in a patient with ischemic cardiomyopathy whose VTs were unrelated to underlying infarct substrate.