Insights into the mechanism of idiopathic left ventricular tachycardia: a case report and literature review

Abstract

Left ventricular posterior fascicular tachycardia (LVPFT) is an idiopathic form of VT characterized by right bundle branch block morphology and left axis deviation. The mechanism of LPFVT is thought to be localized reentry close to the posterior fascicle. We present the case of a 24-year-old medical student who was admitted to the emergency department complaining of palpitations. The ECG showed an aspect suggestive of LVPFT. Vagal maneuvers, adenosine and i.v. Metoprolol were ineffective in terminating the arrhythmia. Conversion to sinus rhythm was obtained 10 h later, with i.v Amiodarone. The ECG in sinus rhythm showed left posterior fascicular block. Because antiarrhythmic drugs were not desired by the patient, VT ablation was proposed. The electrophysiological study identified the mechanism of arrhythmia to be reentry using the slowly conducting verapamil-sensitive fibers as the antegrade limb and the posterior fascicle as the retrograde limb. Radiofrequency applications near the posterior fascicle, in the lower half of the interventricular septum, at the junction of the two proximal thirds with the distal third interrupted the tachycardia and made it non-inducible at programmed stimulation. The case is unusual as the patient had a left posterior fascicular block during sinus rhythm before ablation. This demonstrates that the reentry circuit of VT does not need antegrade conduction through the posterior fascicle for perpetuation.

Ventricular Arrhythmias in the Patient with a Structurally Normal Heart

“…55 It is hypothesized that the slow conduction necessary to sustain reentry results either from this tissue itself or from stretch exerted by the false tendon on normal Purkinje tissue in the LV septum. 60 However, the relatively high prevalence of LV false tendons in the general population makes their specificity for fascicular VT as an underlying arrhythmia mechanism low. 61…”

“…57 Rarely, VT may involve the left anterior fascicle, resulting in a RBBB morphology and left posterior hemiblock pattern. 57,60 More rarely, this may result in VT with a normal frontal plane axis, reflecting its origin in the upper LV septum. 57,60 The retrograde transaortic approach is preferred for fascicular VT mapping and ablation, though the procedure can also be performed via transseptal puncture.…”

“…57,60 More rarely, this may result in VT with a normal frontal plane axis, reflecting its origin in the upper LV septum. 57,60 The retrograde transaortic approach is preferred for fascicular VT mapping and ablation, though the procedure can also be performed via transseptal puncture. 57 With the ablation catheter in the LV, the septum is mapped from the apex to base to identify a target site.…”

Belhassen Tachycardia in a Pediatric Patient: A Simulation for Pediatric Emergency Medicine Fellows

“…Belhassen tachycardia typically presents in older children, adolescents, and young adults and mimics SVT with aberrancy, right bundle branch block, and left anterior hemiblock [ 2 , 3 ]. There have also been case reports in infants and young children [ 4 ].…”