Bundle-Branch Reentry and the Postpacing Interval After Entrainment by Right Ventricular Apex Stimulation

Merino, José Luís; Peinado, Rafaél; Fernández‐Lozano, Ignacio; López‐Gil, María; Arribas, Fernando; Ramírez, Laura; Echeverría, Ignacio; Sobrino, José A.

doi:10.1161/01.cir.103.8.1102

Cited by 74 publications

(11 citation statements)

References 18 publications

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“…Merino et al reported that a difference of <30 ms between PPI and tachycardia CL by entrainment pacing from the RVA was suggestive of BBRVT. 3 Furthermore, the CL of the InterFVT was longer than that of the BBRVT in the present case. Since the conduction in the LPF and LAF was slow due to extensive anterior MI, apparently shorter circuit of the InterFVT yielded a longer CL.…”

mentioning

confidence: 39%

Spontaneous Transition of Wide QRS Tachycardia: What Is the Mechanism?

Hayashi

Fukamizu

Momomura

et al. 2013

Pacing Clinical Electrophis

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Case PresentationA 73-year-old man with a prior anterior myocardial infarction (MI; left ventricular ejection fraction 30%) experienced recurrent ventricular tachycardia (VT). He was referred to our hospital for implantation of an implantable cardioverter defibrillator (ICD). On admission, the electrocardiogram (ECG) showed sinus rhythm with right axis deviation and right bundle branch block (RBBB) morphology, and presence of old extensive anterior MI (Fig. 1A). During the electrophysiological study, two types of monomorphic VT (VT1, VT2) were induced by programmed ventricular stimulation during isoproterenol infusion. VT1 had QRS morphology of RBBB with northwest axis ( Fig. 1B; cycle length [CL], 400 ms), whereas VT2 had QRS morphology of RBBB with abnormal left axis deviation ( Fig. 1B; CL 350 ms). A 3.5-mm irrigated-tip catheter (ThermoCool, Biosense Webster, Diamond Bar, CA, USA) was introduced into the left ventricle along the left posterior fascicle (LPF) during VT1 (Fig. 2C). The LPF-LPF intervals dictated subsequent interventricular (V-V) intervals with atrioventricular dissociation, and the activation sequence of the LPF was from proximal to distal (Fig. 2D). In addition, the Hisventricular (HV) interval was 65 ms during sinus rhythm ( Fig. 2A) and decreased to 40 ms during VT1 (Fig. 2B). VT2 was similar to VT1 in that the LPF-LPF intervals dictated subsequent V-V intervals with atrioventricular dissociation, and the activation sequence of the LPF was from proximal to distal (Fig. 2D). Postpacing interval (PPI) from the right ventricular apex (RVA) was equal to tachycardia CL during VT2 (Fig. 3). Interestingly, spontaneous transition from VT1 to VT2 or vice versa was observed (Figs. 1B and 2D). Figure 2D shows intracardiac electrogram during a transition from VT2 to VT1. On the basis of these observations, what were the mechanisms of VT1 and VT2, and their transition?Commentary Atrioventricular dissociation during wide QRS tachycardia precludes most forms of supraventricular tachycardia as a diagnosis. Mechanisms of VT are either focal or macroreentry. In this context, specific macroreentry mechanisms would include scar-related reentry, bundle-branch reentry, interfascicular reentry, and intrafascicular reentry.During both VT1 and VT2, the LPF-LPF intervals dictated subsequent V-V intervals, and the activation sequence of the LPF was from proximal to distal. This observation indicated that the circuit of these VTs included the His-Purkinje system, whereas scar-related reentrant VT was excluded. Although automatic fascicular tachycardia originating from the LPF is considered as the mechanism of VT, the initiation of tachycardia by programmed stimulation is inconsistent with automatic mechanism. In left posterior Purkinje reentry (intrafascicular VT; IntraFVT), presystolic Purkinje potentials are recorded earlier in the distal portion than those in the basal portion; therefore, the sequence is in the reverse direction to that in bundle branch reentrant VT (BBRVT) or interfascicular VT (InterFVT, Fig. 4).1...

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mentioning

confidence: 39%

Spontaneous Transition of Wide QRS Tachycardia: What Is the Mechanism?

Hayashi

Fukamizu

Momomura

et al. 2013

Pacing Clinical Electrophis

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“…4) were defined as sharp, high-frequency potentials preceding the QRS onset during sinus rhythm. Bundle branch re-entry was ruled out by standard criteria (12). …”

Section: Methodsmentioning

confidence: 99%

Septal Involvement in Patients With Post-Infarction Ventricular Tachycardia

Yoshida¹,

Yokokawa²,

Desjardins³

et al. 2011

Journal of the American College of Cardiology

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Objectives The purpose of this study was to assess the prevalence of the re-entry circuit within the interventricular septum in post-infarction patients referred for ventricular tachycardia (VT) ablation. Background Post-infarction ventricular tachycardia can involve the endocardial myocardium, the intramural myocardium, the epicardium, or the His Purkinje system. Methods Among 74 consecutive patients with recurrent post-infarction VT, 33 patients (45%) were identified in whom the critical part of the VT involved the interventricular septum. A total of 206 VTs were induced in these 33 patients. In 46 of the 206 VTs, a critical component was identified in the interventricular septum. The critical isthmus of the re-entry circuit was identified by entrainment mapping, activation mapping, or pace-mapping. Results In 32 of 46 VTs (70%), the critical component of the re-entry circuit was confined to the endocardium. In 9 of 46 VTs (20%), the critical component involved the Purkinje system, and in 5 of 46 VTs (11%), an intramural area was critical. Entrainment and/or pace-mapping helped to identify critical areas of endocardial VTs as well as VTs involving the Purkinje fibers, but neither of these mapping techniques localized intramural VTs. Electrocardiographic characteristics were specific for each of the septal locations. All VTs mapped to the interventricular septum were acutely successfully ablated. VTs recurred in 9 of 33 patients with septal VTs during a mean follow-up period of 40 ± 20 months. Conclusions Post-infarction VT involving the interventricular septum can involve the endocardial muscle, Purkinje fibers, or intramural muscle fibers. Electrocardiographic characteristics differ depending on the type of tissue involved.

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“… Idiopathic VT Sites Right ventricular outflow tract and pulmonary arteryLeft ventricular outflow tractAortic cuspsMitral and tricuspid annulusEpicardial basal VTIntrafascicular verapamil-sensitive reentrant tachycardiaPapillary muscles 120 Mapping techniques 121 Activation mapping and pace-mappingIdentification of Purkinje potentials, entrainment mappingApproach: Transvenous right ventricular, retrograde aortic, transseptal, coronary venous system, percutaneous epicardial approach Catheter ablation for non-ischemic cardiomyopathy 122,123 Myocardial VT Mechanism: Reentry within the myocardiumLocation: Basal left ventricle, epicardium, right ventricleAblation: Guided by pace-mapping, entrainment mapping, isolated potentialsBundle branch reentry 124 Generally occurs in patients with diffuse conduction system diseaseRole of different maneuvers, comparison of HH and VV intervals, postpacing interval Catheter ablation of post-infarction VT 125,126 Most appropriate as palliative therapy for frequent VT in patients with implantable defibrillatorsPotential role for prevention of ICD dischargesMechanism is reentry using surviving myocytes within scar tissueMapping: Entrainment if hemodynamically tolerated, pace-mapping for non-tolerated VTs, identification of isolated potentials Catheter ablation of frequent PVCs in patients with cardiomyopathy 127 and PVC-induced ventricular fibrillation (VF) or polymorphic VT 128 Recognize the relation of frequent PVCs in cardiomyopathy that is reversible with radiofrequency ablation. Ventricular fibrillation or polymorphic VT triggered by PVCs can be controlled by ablation of the initiating PVCs.…”

Section: Ablation Of Vtmentioning

confidence: 99%

“…Catheter ablation for non-ischemic cardiomyopathy 122,123 Myocardial VT Mechanism: Reentry within the myocardiumLocation: Basal left ventricle, epicardium, right ventricleAblation: Guided by pace-mapping, entrainment mapping, isolated potentialsBundle branch reentry 124 Generally occurs in patients with diffuse conduction system diseaseRole of different maneuvers, comparison of HH and VV intervals, postpacing interval…”

Section: Ablation Of Vtmentioning

confidence: 99%