1
|
Macías Y, Tretter JT, Anderson RH, Sánchez-Quintana D, Soares Correa F, Farré J, Back Sternick E. Miniseries 1-Part IV: How frequent are fasciculo-ventricular connections in the normal heart? Europace 2022; 24:464-472. [PMID: 34999781 DOI: 10.1093/europace/euab286] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Seeking to account for accessory atrioventricular conduction potentially leading to ventricular pre-excitation, Mahaim in the mid-20th century had described pathways between the atrioventricular conduction axis and the muscular ventricular septum. We aimed to look for such 'paraspecific' connections in adult human hearts. METHODS AND RESULTS We serially sectioned 21 hearts, covering the triangle of Koch and the aortic root, and assessing the atrioventricular node, the penetration of the conduction axis, and the bundle branches in our search for fasciculo-ventricular connections. We also calculated the length of the non-branching bundle, and if present the origin of the fasciculo-ventricular connections. The non-branching bundle was 3.6 ± 1.7 mmin length, varying from 1.7 mm to 7.2 mm. Fasciculo-ventricular connections were found in more than half of the hearts, making direct contact with the muscular septum at an average of 3.5 ± 1.7 mm from the origin of the left bundle branch, with the site of origin varying from 1.1 mm to 5.5 mm from the first fascicle of the left bundle branch. In three hearts, additional fasciculo-fascicular connections were observed in the left bundle branch. Two loops were small, but one loop extended over 9.5 mm. CONCLUSION We endorse the finding of Mahaim that fasciculo-ventricular pathways exist in most human hearts. We presume the identified connections had the capability of producing ventricular pre-excitation. More studies are needed to determine the potential clinical manifestations.
Collapse
Affiliation(s)
- Yolanda Macías
- Faculty of Medicine, Department of Human Anatomy and Cell Biology, University of Extremadura, Badajoz, Spain
| | - Justin T Tretter
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Damián Sánchez-Quintana
- Faculty of Medicine, Department of Human Anatomy and Cell Biology, University of Extremadura, Badajoz, Spain
| | - Frederico Soares Correa
- Department of Arrhythmia and Electrophysiology, Biocor Instituto, Nova Lima, Minas Gerais, Brazil
| | - Jerónimo Farré
- Fundación Jiménez Díaz University Hospital and Institute of Biomedical Research, Madrid, Spain
| | - Eduardo Back Sternick
- Department of Medical and Surgical Therapeutics, Veterinary Faculty, University of Extremadura, Cáceres, Spain
| |
Collapse
|
2
|
Sung RK, Boyden PA, Higuchi S, Scheinman M. Diagnosis and Management of Complex Reentrant Arrhythmias Involving the His-Purkinje System. Arrhythm Electrophysiol Rev 2021; 10:190-197. [PMID: 34777824 PMCID: PMC8576512 DOI: 10.15420/aer.2021.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/13/2021] [Indexed: 11/04/2022] Open
Abstract
The His-Purkinje system is a network of bundles and fibres comprised of specialised cells that allow for coordinated, synchronous activation of the ventricles. Although the histology and physiology of the His-Purkinje system have been studied for more than a century, its role in ventricular arrhythmias has recently been discovered with the ongoing elucidation of the mechanisms leading to both benign and life-threatening arrhythmias. Studies of Purkinje-cell electrophysiology show multiple mechanisms responsible for ventricular arrhythmias, including enhanced automaticity, triggered activity and reentry. The variation in functional properties of Purkinje cells in different areas of the His-Purkinje system underlie the propensity for reentry within Purkinje fibres in structurally normal and abnormal hearts. Catheter ablation is an effective therapy in nearly all forms of reentrant arrhythmias involving Purkinje tissue. However, identifying those at risk of developing fascicular arrhythmias is not yet possible. Future research is needed to understand the precise molecular and functional changes resulting in these arrhythmias.
Collapse
Affiliation(s)
| | | | - Satoshi Higuchi
- University of California San Francisco, San Francisco, CA, US
| | | |
Collapse
|
3
|
Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 219] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
Collapse
Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
| | | | | | | | | | | | | | | |
Collapse
|
4
|
Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
Collapse
Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
| | | | | | | | | | | | | |
Collapse
|
5
|
Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
Collapse
Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
| | | | | | | | | | | | | |
Collapse
|
6
|
He BJ, Boyden P, Scheinman M. Ventricular arrhythmias involving the His-Purkinje system in the structurally abnormal heart. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1051-1059. [PMID: 30084120 DOI: 10.1111/pace.13465] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/28/2018] [Accepted: 07/05/2018] [Indexed: 12/01/2022]
Abstract
His-Purkinje-related ventricular arrhythmias are a subset of ventricular tachycardias that use the specialized cardiac conduction system. These arrhythmias can occur in various different forms of structural heart disease. Here, we review the basic science discoveries and their analogous clinical observations that implicate the His-Purkinje system as a crucial component of the arrhythmia circuit. While mutations serve the molecular basis for arrhythmias in the heritable cardiomyopathies, transcriptional and posttranslational changes constitute the adverse remodeling leading to arrhythmias in acquired structural heart disease. Additional studies on the electrical properties of the His-Purkinje network and its interactions with the surrounding myocardium will improve the clinical diagnosis and treatment of these arrhythmias.
Collapse
Affiliation(s)
- Beixin Julie He
- Department of Medicine, University of California, San Francisco, California
| | - Penelope Boyden
- Department of Pharmacology, Columbia University, New York city, New York
| | - Melvin Scheinman
- Department of Medicine, University of California, San Francisco, California
| |
Collapse
|
7
|
Fisher JD. Hemiblocks and the fascicular system: myths and implications. J Interv Card Electrophysiol 2018; 52:281-285. [DOI: 10.1007/s10840-018-0440-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
|
8
|
Reithmann C. [Bundle branch reentry VT : Diagnosis, mapping, and ablation]. Herzschrittmacherther Elektrophysiol 2017; 28:193-198. [PMID: 28484841 DOI: 10.1007/s00399-017-0502-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 04/10/2017] [Indexed: 11/26/2022]
Abstract
Macroreentry in the His-Purkinje system can result in sustained ventricular tachycardia (VT) termed bundle branch reentry VT. Bundle branch reentry is usually associated with His-Purkinje disease and depressed left ventricular function. In the case of typical bundle branch reentry, the right bundle is activated in the anterograde direction and ventricular depolarization begins at the distal end of the right bundle on the ventricular septum generating a typical left bundle branch block QRS morphology. However, atypical surface ECGs can also be found in patients with severe left ventricular dysfunction and involvement of the right ventricle complicating the diagnosis of bundle branch reentry VT. It is important to diagnose bundle branch reentry VT because patients with bundle branch reentry VT may suffer from a high rate of serial implantable cardioverter defibrillator (ICD) interventions based on VT recurrences due to immediate reinitiation of the arrhythmia. Ablation of the right bundle branch easily cures bundle branch reentry VT and can prevent frequent ICD interventions. After ablation of bundle branch reentry VT, mortality remains high due to the severe left ventricular dysfunction in many patients, and the patients are candidates for cardiac resynchronization therapy (CRT-D).
Collapse
Affiliation(s)
- Christopher Reithmann
- Medizinische Klinik 1, HELIOS Klinikum München West, Akademisches Lehrkrankenhaus der Ludwig-Maximilians-Universität München, Steinerweg 5, 81241, München, Deutschland.
| |
Collapse
|
9
|
Reithmann C, Fiek M, Herkommer B, Mulser R. Purkinje-related trigger and substrate of recurrent ventricular tachycardia in a patient with ischemic cardiomyopathy. Clin Res Cardiol 2017; 106:656-659. [PMID: 28337551 DOI: 10.1007/s00392-017-1103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 03/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Christopher Reithmann
- Department of Medicine 1, HELIOS Clinic Munich West, Academic Hospital of the University of Munich, Munich, Germany. .,Medizinische Klinik 1, HELIOS Klinik München West, Akademisches Lehrkrankenhaus der Ludwig-Maximilians Universität München, Steinerweg 5, Munich, 81241, Germany.
| | - Michael Fiek
- Department of Medicine 1, HELIOS Clinic Munich West, Academic Hospital of the University of Munich, Munich, Germany
| | - Bernhard Herkommer
- Department of Medicine 1, HELIOS Clinic Munich West, Academic Hospital of the University of Munich, Munich, Germany
| | - Ruth Mulser
- Department of Medicine 1, HELIOS Clinic Munich West, Academic Hospital of the University of Munich, Munich, Germany
| |
Collapse
|
10
|
Durrani SA, Sung R, Scheinman M. Bidirectional Ventricular Tachycardia Due to a Mixture of Focal Fascicular Firing and Reentry. Card Electrophysiol Clin 2016; 8:753-764. [PMID: 27837895 DOI: 10.1016/j.ccep.2016.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Bidirectional ventricular tachycardia (BDVT) is a well-known phenomenon since it was first described in 1922. Various mechanisms have been proposed for BDVT, including digitalis toxicity, hypokalemia, Anderson-Tawil syndrome, acute myocarditis, and catecholaminergic polymorphic ventricular tachycardia. It is characterized by rapid, wide complex electrocardiogram pattern with alternating QRS morphology and axis. The alternation of the QRS is usually right bundle branch block with 180° swings in the frontal plane axis or, less commonly, alternation of right bundle branch and left bundle branch forms. Most of the proposed mechanisms involve triggered activity or enhanced automaticity. We describe a unique BDVT, with characteristics of both re-entry and triggered activity, which terminated with a focal Rf lesion.
Collapse
Affiliation(s)
- Sarfraz A Durrani
- MedStar Heart and Vascular Institute, #501 Hamaker court, Fairfax, VA 22031, USA.
| | - Raphael Sung
- Peninsula Primary Care, Cardiology, 30 Garden Court, Suite B, Monterey, CA 93940, USA
| | - Melvin Scheinman
- University of California San Francisco Medical Center, 500 Parnassus Avenue, MUE 436, San Francisco, CA 94143-1354, USA
| |
Collapse
|
11
|
Abstract
Fascicular arrhythmias encompass a wide spectrum of ventricular arrhythmias that depend on the specialized conduction system of the right and left ventricles. These arrhythmias include premature ventricular complexes, monomorphic ventricular tachycardia, polymorphic ventricular tachycardia, and ventricular fibrillation. These arrhythmias may be organized by mechanism, including intrafascicular reentry, interfascicular reentry, and focal. Mapping and ablation of the fascicular system can result in high cure rates of debilitating and potentially life-threatening arrhythmias. When approaching these arrhythmias, careful consideration of the structure of the His Purkinje system as well as their electrophysiologic properties may help guide even the most complex of arrhythmias.
Collapse
Affiliation(s)
- Raphael Sung
- Community Hospital of the Monterey Peninsula, Monterey, CA, USA
| | - Melvin Scheinman
- University of California San Francisco, 350 Parnassus Avenue, #300, San Francisco, CA 94117, USA.
| |
Collapse
|
12
|
Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekvål TM, Spaulding C, Van Veldhuisen DJ. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC)Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Europace 2015; 17:1601-87. [PMID: 26318695 DOI: 10.1093/europace/euv319] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
13
|
Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekvål TM, Spaulding C, Van Veldhuisen DJ. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015; 36:2793-2867. [PMID: 26320108 DOI: 10.1093/eurheartj/ehv316] [Citation(s) in RCA: 2523] [Impact Index Per Article: 280.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
MESH Headings
- Acute Disease
- Aged
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmias, Cardiac/genetics
- Arrhythmias, Cardiac/therapy
- Autopsy/methods
- Cardiac Resynchronization Therapy/methods
- Cardiomyopathies/complications
- Cardiomyopathies/therapy
- Cardiotonic Agents/therapeutic use
- Catheter Ablation/methods
- Child
- Coronary Artery Disease/complications
- Coronary Artery Disease/therapy
- Death, Sudden, Cardiac/prevention & control
- Defibrillators
- Drug Therapy, Combination
- Early Diagnosis
- Emergency Treatment/methods
- Female
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/therapy
- Heart Transplantation/methods
- Heart Valve Diseases/complications
- Heart Valve Diseases/therapy
- Humans
- Mental Disorders/complications
- Myocardial Infarction/complications
- Myocardial Infarction/therapy
- Myocarditis/complications
- Myocarditis/therapy
- Nervous System Diseases/complications
- Nervous System Diseases/therapy
- Out-of-Hospital Cardiac Arrest/therapy
- Pregnancy
- Pregnancy Complications, Cardiovascular/therapy
- Primary Prevention/methods
- Quality of Life
- Risk Assessment
- Sleep Apnea, Obstructive/complications
- Sleep Apnea, Obstructive/therapy
- Sports/physiology
- Stroke Volume/physiology
- Terminal Care/methods
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/therapy
Collapse
|
14
|
Okishige K, Sakurada H, Mizusawa Y, Yamauchi Y, Fukamizu S, Aoyagi H, Okano Y, Azegami K, Sasano T, Hirao K. The radio frequency catheter ablation of inter-fascicular reentrant tachycardia: new insights into the electrophysiological and anatomical characteristics. J Interv Card Electrophysiol 2014; 41:39-54. [DOI: 10.1007/s10840-014-9911-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 04/28/2014] [Indexed: 11/29/2022]
|
15
|
Iyer V, Sampson KJ, Kass RS. Modeling tissue- and mutation- specific electrophysiological effects in the long QT syndrome: role of the Purkinje fiber. PLoS One 2014; 9:e97720. [PMID: 24892747 PMCID: PMC4043730 DOI: 10.1371/journal.pone.0097720] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 03/28/2014] [Indexed: 12/05/2022] Open
Abstract
Congenital long QT syndrome is a heritable family of arrhythmias caused by mutations in 13 genes encoding ion channel complex proteins. Mounting evidence has implicated the Purkinje fiber network in the genesis of ventricular arrhythmias. In this study, we explore the hypothesis that long QT mutations can demonstrate different phenotypes depending on the tissue type of expression. Using computational models of the human ventricular myocyte and the Purkinje fiber cell, the biophysical alteration in channel function in LQT1, LQT2, LQT3, and LQT7 are modeled. We identified that the plateau potential was important in LQT1 and LQT2, in which mutation led to minimal action potential prolongation in Purkinje fiber cells. The phenotype of LQT3 mutation was dependent on the biophysical alteration induced as well as tissue type. The canonical ΔKPQ mutation causes severe action potential prolongation in both tissue types. For LQT3 mutation F1473C, characterized by shifted channel availability, a more severe phenotype was seen in Purkinje fiber cells with action potential prolongation and early afterdepolarizations. The LQT3 mutation S1904L demonstrated striking effects on action potential duration restitution and more severe action potential prolongation in Purkinje fiber cells at higher heart rates. Voltage clamp simulations highlight the mechanism of effect of these mutations in different tissue types, and impact of drug therapy is explored. We conclude that arrhythmia formation in long QT syndrome may depend not only on the basis of mutation and biophysical alteration, but also upon tissue of expression. The Purkinje fiber network may represent an important therapeutic target in the management of patients with heritable channelopathies.
Collapse
Affiliation(s)
- Vivek Iyer
- Department of Pharmacology, College of Physicians and Surgeons of Columbia University, New York, New York, United States of America
- * E-mail:
| | - Kevin J. Sampson
- Department of Pharmacology, College of Physicians and Surgeons of Columbia University, New York, New York, United States of America
| | - Robert S. Kass
- Department of Pharmacology, College of Physicians and Surgeons of Columbia University, New York, New York, United States of America
| |
Collapse
|
16
|
Dobrzynski H, Anderson RH, Atkinson A, Borbas Z, D'Souza A, Fraser JF, Inada S, Logantha SJRJ, Monfredi O, Morris GM, Moorman AFM, Nikolaidou T, Schneider H, Szuts V, Temple IP, Yanni J, Boyett MR. Structure, function and clinical relevance of the cardiac conduction system, including the atrioventricular ring and outflow tract tissues. Pharmacol Ther 2013; 139:260-88. [PMID: 23612425 DOI: 10.1016/j.pharmthera.2013.04.010] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 03/28/2013] [Indexed: 01/01/2023]
Abstract
It is now over 100years since the discovery of the cardiac conduction system, consisting of three main parts, the sinus node, the atrioventricular node and the His-Purkinje system. The system is vital for the initiation and coordination of the heartbeat. Over the last decade, immense strides have been made in our understanding of the cardiac conduction system and these recent developments are reviewed here. It has been shown that the system has a unique embryological origin, distinct from that of the working myocardium, and is more extensive than originally thought with additional structures: atrioventricular rings, a third node (so called retroaortic node) and pulmonary and aortic sleeves. It has been shown that the expression of ion channels, intracellular Ca(2+)-handling proteins and gap junction channels in the system is specialised (different from that in the ordinary working myocardium), but appropriate to explain the functioning of the system, although there is continued debate concerning the ionic basis of pacemaking. We are beginning to understand the mechanisms (fibrosis and remodelling of ion channels and related proteins) responsible for dysfunction of the system (bradycardia, heart block and bundle branch block) associated with atrial fibrillation and heart failure and even athletic training. Equally, we are beginning to appreciate how naturally occurring mutations in ion channels cause congenital cardiac conduction system dysfunction. Finally, current therapies, the status of a new therapeutic strategy (use of a specific heart rate lowering drug) and a potential new therapeutic strategy (biopacemaking) are reviewed.
Collapse
|
17
|
MIYAZAKI SHINSUKE, TANIGUCHI HIROSHI, UCHIYAMA TAKASHI, KOURA KENJI, TAKAYAMA KEI, KUSA SHIGEKI, IESAKA YOSHITO. Wide QRS Tachycardia: What Is the Mechanism? J Cardiovasc Electrophysiol 2012; 23:1398-9. [DOI: 10.1111/j.1540-8167.2012.02323.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
18
|
SUNG RAPHAELK, KIM ALBERTM, TSENG ZIANH, HAN FREDERICK, INADA KEIICHI, TEDROW USHAB, VISWANATHAN MOHANN, BADHWAR NITISH, VAROSY PAULD, TANEL RONN, OLGIN JEFFREYE, STEPHENSON WILLIAMG, SCHEINMAN MELVIN. Diagnosis and Ablation of Multiform Fascicular Tachycardia. J Cardiovasc Electrophysiol 2012; 24:297-304. [DOI: 10.1111/jce.12020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
19
|
The risk of delayed atrioventricular and intraventricular conduction block following ablation of bundle branch reentry. Clin Res Cardiol 2012; 102:145-53. [PMID: 23015015 DOI: 10.1007/s00392-012-0509-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 09/11/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The aim of the study was to determine the long-term reliability of atrioventricular and intraventricular conduction and the implications for cardiac resynchronization therapy (CRT-D) following catheter ablation of bundle branch reentry tachycardia (BBRT) and interfascicular tachycardia. METHODS AND RESULTS Fourteen patients with recurrent monomorphic ventricular tachycardia (VT) (n = 11) and incessant VT (n = 3) underwent catheter ablation of BBRT (n = 7), interfascicular tachycardia (n = 5) or both arrhythmias (n = 2). Successful ablation was achieved in all patients without intraprocedural atrioventricular (AV) block. Within 2 months after ablation, three patients with BBRT and pre-existing prolonged QRS developed a delayed third-degree AV block. During the follow-up of 2 years, two patients with interfascicular tachycardia developed a new left bundle branch block (LBBB) associated with worsening of heart failure. Three patients underwent upgrading of implantable cardioverter defibrillator therapy to CRT-D early after ablation which improved heart failure during the 6 months follow-up. During the long-term follow-up of 39 ± 13 months, VT storm recurred in one patient. Four of the 14 patients died of deterioration of heart failure and one had to undergo heart transplantation. CONCLUSIONS Catheter ablation for BBRT in patients with prolonged QRS is associated with a high risk of delayed third-degree AV block. Ablation of interfascicular tachycardia can be associated with delayed LBBB. After ablation of bundle branch reentry, patients with prolonged QRS are candidates for cardiac resynchronization therapy but the mortality remains high.
Collapse
|
20
|
Metzner A, Ouyang F, Wissner E, Kuck KH. Monomorphic and polymorphic ventricular tachycardias arising from the His–Purkinje system: what do we know? Future Cardiol 2011; 7:835-46. [DOI: 10.2217/fca.11.60] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Monomorphic and polymorphic Purkinje-related ventricular tachycardias (VTs) may occur in patients with and without underlying structural heart disease. Monomorphic Purkinje-related VTs can be divided into different entities: verapamil-sensitive left fascicular VTs; bundle branch reentry tachycardias (BBRT); interfascicular VTs and focal Purkinje VTs. The most frequent fascicular VT is left posterior fascicular VT, characterized by macro-reentry within the posterior Purkinje network. However, the reentry may also be located in the anterior Purkinje network (left anterior fascicular VT). BBRT is also a macro-reentry-tachycardia, utilizing both the right and the left bundle branch as the antegrade and the retrograde limb and is often associated with pre-existing conduction disturbances in the specific conduction system. Interfascicular VT is rare and characterized by a macro-reentry within the left fascicles. BBRT and interfascicular VT may also occur in the same patient. In contrast to the mentioned macro-reentry mechanisms there are focal Purkinje-related VTs arising from the anterior or posterior Purkinje system. Focal Purkinje triggered premature ventricular contractions originating from the distal Purkinje arborization in patients without a structural heart disease, as well as in patients with known ischemic heart disease or an underlying channelopathy such as Brugada syndrome may induce polymorphic VTs. Catheter ablation is an effective treatment option for both monomorphic as well as polymorphic Purkinje-related VTs, often resulting in noninducibility and freedom from VT recurrence. A systematic analysis of the surface ECG and the intracardiac electrograms is essential for successful ablation of these heterogeneous and potentially curable VTs.
Collapse
Affiliation(s)
| | - Feifan Ouyang
- Asklepios-Klinik St. Georg, Department of Cardiology, Lohmühlenstr. 5, 20099 Hamburg, Germany
| | - Erik Wissner
- Asklepios-Klinik St. Georg, Department of Cardiology, Lohmühlenstr. 5, 20099 Hamburg, Germany
| | - Karl-Heinz Kuck
- Asklepios-Klinik St. Georg, Department of Cardiology, Lohmühlenstr. 5, 20099 Hamburg, Germany
| |
Collapse
|
21
|
Alzand BSN, Crijns HJGM. Diagnostic criteria of broad QRS complex tachycardia: decades of evolution. Europace 2011; 13:465-472. [DOI: 10.1093/europace/euq430] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|
22
|
NOGAMI AKIHIKO. Purkinje-Related Arrhythmias Part I: Monomorphic Ventricular Tachycardias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:624-50. [DOI: 10.1111/j.1540-8159.2011.03044.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
23
|
|
24
|
Abstract
Purkinje cells are specialized for rapid propagation in the heart. Furthermore, Purkinje fibers as the source as well as the perpetuator of arrhythmias is a familiar finding. This is not surprising considering their location in the heart and their unique cell ultrastructure, cell electrophysiology, and mode of excitation-contraction coupling. This review touches on each of these points as we outline what is known today about Purkinje fibers/cells.
Collapse
|
25
|
Yamada T, McElderry HT, Okada T, Murakami Y, Doppalapudi H, Yoshida N, Allred JD, Murohara T, Kay GN. Idiopathic Focal Ventricular Arrhythmias Originating from the Anterior Papillary Muscle in the Left Ventricle. J Cardiovasc Electrophysiol 2009; 20:866-72. [PMID: 19298560 DOI: 10.1111/j.1540-8167.2009.01448.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama 35294-0019, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
REITHMANN CHRISTOPHER, HAHNEFELD ANTON, ULBRICH MICHAEL, MATIS TOMAS, STEINBECK GERHARD. Different Forms of Ventricular Tachycardia Involving the Left Anterior Fascicle in Nonischemic Cardiomyopathy: Critical Sites of the Reentrant Circuit in Low-Voltage Areas. J Cardiovasc Electrophysiol 2009; 20:841-9. [DOI: 10.1111/j.1540-8167.2009.01467.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
27
|
|
28
|
|
29
|
Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jais P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace 2009; 11:771-817. [DOI: 10.1093/europace/eup098] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
30
|
Blanck Z, Sra J, Akhtar M. Incessant interfascicular reentrant ventricular tachycardia as a result of catheter ablation of the right bundle branch: case report and review of the literature. J Cardiovasc Electrophysiol 2009; 20:1279-83. [PMID: 19302481 DOI: 10.1111/j.1540-8167.2009.01459.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 72-year-old woman developed incessant interfascicular (IF) ventricular tachycardia immediately after successful right bundle branch (RBB) catheter ablation for the treatment of sustained bundle branch reentrant tachycardia. Catheter ablation of the left bundle branch and the left anterior fascicle was successful in eliminating the tachycardia (in 2 different sessions). This report discusses the direct link between the creation of an RBB block and the development of IF tachycardia, in our case, and in prior cases of IF reentry reported in the literature.
Collapse
Affiliation(s)
- Zalmen Blanck
- Electrophysiology Laboratories of Aurora St. Luke's and Aurora Sinai Medical Centers, University of Wisconsin School of Medicine and Public Health-Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA.
| | | | | |
Collapse
|
31
|
Reithmann C. Delayed Purkinje potentials during sinus rhythm in post MI patients—an underrecognized target for VT ablation? J Interv Card Electrophysiol 2008; 22:239-41. [DOI: 10.1007/s10840-008-9274-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Accepted: 04/29/2008] [Indexed: 10/22/2022]
|
32
|
Morishima I, Nogami A, Tsuboi H, Sone T. Verapamil-sensitive left anterior fascicular ventricular tachycardia associated with a healed myocardial infarction: changes in the delayed Purkinje potential during sinus rhythm. J Interv Card Electrophysiol 2008; 22:233-7. [DOI: 10.1007/s10840-008-9268-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 04/17/2008] [Indexed: 10/21/2022]
|
33
|
Balasundaram R, Rao HB, Kalavakolanu S, Narasimhan C. Catheter ablation of bundle branch reentrant ventricular tachycardia. Heart Rhythm 2008; 5:S68-72. [DOI: 10.1016/j.hrthm.2008.02.036] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Indexed: 11/27/2022]
|
34
|
Doppalapudi H, Yamada T, McElderry HT, Plumb VJ, Epstein AE, Kay GN. Ventricular Tachycardia Originating From the Posterior Papillary Muscle in the Left Ventricle. Circ Arrhythm Electrophysiol 2008; 1:23-9. [DOI: 10.1161/circep.107.742940] [Citation(s) in RCA: 168] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Several distinct forms of focal ventricular tachycardia (VT) from the left ventricle (LV) have been described. We report a new syndrome of VT arising from the base of the posterior papillary muscle in the LV.
Methods and Results—
Among 290 consecutive patients who underwent ablation for VT or symptomatic premature ventricular complexes (PVCs) based on a focal mechanism, 7 patients were found to have an ablation site at the base of the posterior papillary muscle in the LV. All patients had normal LV systolic function and a normal baseline electrocardiogram. The electrocardiogram during VT or PVCs demonstrated a right bundle-branch block and superior-axis QRS morphology in all patients. VT was not inducible by programmed atrial or ventricular stimulation. In 2 patients with sustained VT, overdrive pacing neither terminated VT nor demonstrated any criterion for transient entrainment. Activation mapping localized the earliest site of activation to the base of the posterior papillary muscle in all patients. When Purkinje potentials were recorded at the site of successful ablation, these potentials preceded local ventricular muscle potentials during sinus rhythm. During VT or PVCs, however, the ventricular muscle potential always preceded the Purkinje potentials. After recurrence of VT or PVCs with standard radiofrequency ablation, irrigated ablation was successful in eliminating the arrhythmia in all patients. Over a mean follow-up period of 9 months, all patients have been free of PVCs and VT.
Conclusion—
We present a distinct syndrome of VT arising from the base of the posterior papillary muscle in the LV by a nonreentrant mechanism. Ablation can be challenging, and irrigated ablation may be necessary for long-term success.
Collapse
Affiliation(s)
- Harish Doppalapudi
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - Takumi Yamada
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - H. Thomas McElderry
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - Vance J. Plumb
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - Andrew E. Epstein
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - G. Neal Kay
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| |
Collapse
|
35
|
Ashino S, Watanabe I, Kofune M, Okumura Y, Kawauchi K, Yamada T, Okubo K, Hashimoto K, Shindo A, Sugimura H, Nakai T, Saito S, Hirayama A. Radiofrequency catheter ablation of ventricular tachycardia originating in the left posterior and left anterior fascicles in a patient with prior myocardial infarction. Int Heart J 2008; 49:119-27. [PMID: 18360070 DOI: 10.1536/ihj.49.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A 61-year-old man with prior anteroseptal myocardial infarction (ejection fraction: 40%) presented with recurrent episodes of palpitations. Twelve-lead ECG during palpitations showed an incessant ventricular tachycardia (VT1) with right bundle branch block (RBBB) morphology and inferior axis. Electrophysiologic study revealed that the clinical VT originated from the anterolateral left ventricle. A Purkinje potential preceded onset of the QRS complex by 34 ms. Radiofrequency ablation guided by the Purkinje potential terminated the VT1. Another ventricular tachycardia (VT2) showing RBBB morphology with superior axis and originating from the posteroseptal left ventricle, was induced by programmed ventricular stimulation. A Purkinje potential preceded onset of the local ventricular potential by 120-130 ms in this VT. Radiofrequency ablation guided by the Purkinje potential terminated the VT2.
Collapse
Affiliation(s)
- Sonoko Ashino
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Reithmann C, Hahnefeld A, Remp T, Steinbeck G. Ventricular Tachycardia With Participation of the Left Bundle-Purkinje System in Patients With Structural Heart Disease: Identification of Slow Conduction During Sinus Rhythm. J Cardiovasc Electrophysiol 2007; 18:808-17. [PMID: 17573838 DOI: 10.1111/j.1540-8167.2007.00880.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Idiopathic left ventricular tachycardia (VT) originating from the left posterior fascicle can be eliminated by ablation at sites with abnormal diastolic potentials (DPs) during sinus rhythm. We investigated whether such DPs can also be recorded in patients with structural heart disease and VT involving the left bundle-Purkinje system. METHODS AND RESULTS Eight patients (mean age 67 +/- 11 years) with nonischemic cardiomyopathy (n = 5) or prior myocardial infarction (n = 3) presented with VT involving the left bundle-Purkinje system (cycle length 376 +/- 45 ms). Three types of VT were observed: macroreentrant VT with participation of both left bundle fascicles in three patients, fascicular VT involving the left posterior fascicle in two patients, and scar-related VT with Purkinje fibers as part of the reentrant circuit in three patients. In all patients, abnormal isolated DPs of low amplitude with a QRS-earliest DP interval of 374 +/- 86 ms were found during sinus rhythm in the mid- or inferior left ventricular septum in areas with Purkinje potentials. The abnormal DPs during sinus rhythm coincided or were in proximity to DPs during the VT in six patients. VT ablation targeting the sites with the earliest abnormal DPs during sinus eliminated the VT in 7 of 8 patients with freedom from VT recurrence in six patients during the follow-up of 11 +/- 5 months. CONCLUSIONS Isolated DPs during sinus rhythm were found in proximity to the posterior Purkinje network in patients with VT involving the left bundle-Purkinje system associated with heart disease and can be used to guide successful catheter ablation.
Collapse
|
37
|
Reithmann C, Hahnefeld A, Oversohl N, Ulbrich M, Remp T, Steinbeck G. Reinitiation of Ventricular Macroreentry within the His-Purkinje System by Back-Up Ventricular Pacing?A Mechanism of Ventricular Tachycardia Storm. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:225-35. [PMID: 17338720 DOI: 10.1111/j.1540-8159.2007.00654.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND We describe immediate reinitiation of macroreentry ventricular tachycardia (VT) involving the His-Purkinje system by ventricular pacing from the electrode of an implantable cardioverter defibrillator (ICD) as a mechanism of VT storm refractory to ICD therapy. METHODS AND RESULTS Repetitive reinitiation of bundle branch reentry tachycardia (BBRT), interfascicular tachycardia, or both VTs by ventricular pacing was identified in four ICD patients presenting with VT storm or incessant VT. All patients had a pre-existing prolonged HV interval (75 +/- 9 ms) and left bundle branch block (LBBB) or bifascicular block during sinus rhythm. The VTs included BBRT with LBBB in three patients and interfascicular tachycardia with right bundle branch block (RBBB) and left anterior or left posterior fascicular block in two patients. The paced beats from the ICD electrode exhibited a LBBB pattern of depolarization in two patients and a RBBB contour in V1 and V2 with left axis deviation in two patients. The QRS complex during pacing from the ICD electrode closely resembled that of the recurrent VT in all four patients suggesting that the pacing site of the ICD electrode was in proximity to the myocardial exit site of the bundle fascicle used for antegrade conduction during the reinitiated VT. Ventricular pacing from the ICD electrode after termination of the VT apparently encountered the retrograde refractoriness of this bundle fascicle and allowed immediate re-propagation of the wavefront orthodromically along the VT circuit. BBRT was eliminated by ablation of the right bundle branch. Successful ablation of the interfascicular tachycardias was achieved by targeting (1) an abnormal potential of the distal left posterior Purkinje network or (2) a diastolic potential during VT in the midinferior left ventricular (LV) septum. CONCLUSIONS Repetitive reinitiation of BBRT and interfascicular tachycardia by ventricular pacing from the ICD electrode should be considered as a mechanism of VT storm refractory to ICD therapy in patients with a pre-existing conduction delay within the His-Purkinje system.
Collapse
|
38
|
Catheter Ablation of Supraventricular and Ventricular Arrhythmias. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
39
|
Hayashi M, Kobayashi Y, Iwasaki YK, Morita N, Miyauchi Y, Kato T, Takano T. Novel mechanism of postinfarction ventricular tachycardia originating in surviving left posterior Purkinje fibers. Heart Rhythm 2006; 3:908-18. [PMID: 16876739 DOI: 10.1016/j.hrthm.2006.04.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Accepted: 04/13/2006] [Indexed: 01/08/2023]
Abstract
BACKGROUND Other than bundle branch reentry and interfascicular reentry, monomorphic postmyocardial infarction (post-MI) reentrant ventricular tachycardia (VT) including the His-Purkinje system has not been reported. Verapamil-sensitive idiopathic left VT includes the left posterior Purkinje fibers but develops in patients without structural heart disease. OBJECTIVES The purpose of this study was to describe a novel mechanism of reentrant VT arising from the left posterior Purkinje fibers in patients with a prior MI. METHODS The study consisted of four patients with a prior MI and symptomatic heart failure who underwent electrophysiologic study and catheter ablation for VT showing right bundle branch block (n = 3) or atypical left bundle branch block (n = 1) morphology with superior axis. In two patients, the VT frequently emerged during the acute phase of MI and required emergency catheter ablation. RESULTS Clinical VT was reproducibly induced by programmed stimulation. In three patients, both diastolic and presystolic Purkinje potentials were sequentially recorded along the left ventricular posterior septum during the VT, whereas in the fourth patient, only presystolic Purkinje potentials were observed. During entrainment pacing from the right atrium, diastolic Purkinje potentials were captured orthodromically and demonstrated decremental conduction properties, whereas presystolic Purkinje potentials were captured antidromically and appeared between the His and QRS complex. Radiofrequency energy delivered at the site exhibiting a Purkinje-QRS interval of 58 +/- 26 ms successfully eliminated the VTs without provoking any conduction disturbances. CONCLUSION Reentrant monomorphic VT originating from the left posterior Purkinje fibers, which is analogous to idiopathic left VT, can develop in the acute or chronic phase of MI. Catheter ablation is highly effective in eliminating this VT without affecting left ventricular conduction.
Collapse
Affiliation(s)
- Meiso Hayashi
- First Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | | | | | | | | | | | | |
Collapse
|
40
|
Sternick EB. Tachycardia with VA dissociation: an unusual tachycardia mechanism. J Cardiovasc Electrophysiol 2006; 16:1395; author reply 1395. [PMID: 16403085 DOI: 10.1111/j.1540-8167.2005.280_1.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
41
|
Affiliation(s)
- Mark E Josephson
- Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| |
Collapse
|
42
|
Lopera G, Stevenson WG, Soejima K, Maisel WH, Koplan B, Sapp JL, Satti SD, Epstein LM. Identification and Ablation of Three Types of Ventricular Tachycardia Involving the His-Purkinje System in Patients with Heart Disease. J Cardiovasc Electrophysiol 2004; 15:52-8. [PMID: 15028072 DOI: 10.1046/j.1540-8167.2004.03189.x] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Ventricular tachycardia (VT) with involvement of the His-Purkinje system (HPS) can be difficult to recognize in patients with heart disease, but it may be particularly susceptible to ablation targeting the HPS. This study defines the incidence and types of HPS involvement in VT. METHODS AND RESULTS Involvement of the HPS was sought during electrophysiologic study with catheter mapping in 234 consecutive patients referred for catheter ablation of recurrent VT associated with heart disease. HPS VT was observed in 20 (8.5%) patients (mean ejection fraction 29%+/- 17%); in 9 (11%) of 81 patients with nonischemic heart disease and 11 (7.1%) of 153 patients with coronary artery disease (P = NS). Three types of HPS VT were observed: 16 patients (group 1) had typical bundle branch reentry, 2 patients (group 2) had bundle branch reentry and interfascicular reentry, and 2 patients (group 3) had VT consistent with a focal origin in the distal HPS. In all three groups, the VT QRS had morphologic similarity to the sinus rhythm QRS. Ablation of HPS VT was successful in all patients in whom it was attempted but produced high-degree AV block in 6 (30%). In 12 patients (60%), other VTs due to reentry through scar also were inducible. CONCLUSION Involvement of the HPS in VT associated with heart disease has three distinct clinical forms, all of which are susceptible to ablation. Ablation often is not sufficient as the sole therapy due to other induced VT's and conduction abnormalities, requiring pacemaker and/or defibrillator implantation.
Collapse
Affiliation(s)
- Gustavo Lopera
- Cardiovascular Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Josephson ME. Electrophysiology of Ventricular Tachycardia:. A Historical Perspective. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2003; 26:2052-67. [PMID: 14516353 DOI: 10.1046/j.1460-9592.2003.00320.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mark E Josephson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
| |
Collapse
|
44
|
Affiliation(s)
- John M Morgan
- Wessex Cardiothoracic Centre, Southampton SO16 6YD, UK.
| |
Collapse
|
45
|
Arnar DO, Xing D, Lee H, Martins JB. Prevention of ischemic ventricular tachycardia of Purkinje origin: role for alpha(2)-adrenoceptors in Purkinje? Am J Physiol Heart Circ Physiol 2001; 280:H1182-90. [PMID: 11179062 DOI: 10.1152/ajpheart.2001.280.3.h1182] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recent studies have shown the presence of postjunctional alpha(2)-adrenergic receptors on canine Purkinje fibers but not muscle cells. Stimulation of these receptors results in prolongation of the action potential duration and the Purkinje relative refractory period. We studied the effect of alpha(2)-adrenergic agonists on inducible ischemic ventricular tachycardia (VT) of both Purkinje fiber and myocardial origin. Open-chest dogs in whom VT was induced with extrastimuli after occlusion of the anterior descending coronary artery were studied. A mapping system, incorporating Purkinje signals, characterized the mechanisms of VT. The alpha(2)-adrenergic agonists clonidine (0.5-4.0 microg/kg) or UK 14,304 (4-5 microg/kg) versus saline were given intravenously after reproducibility of inducible sustained monomorphic VT had been demonstrated. Eighteen dogs were given clonidine, eleven of which had focal Purkinje VT. Of these 11 dogs, clonidine blocked VT induction in 9 (81.9%) and rendered VT nonsustained in 1 (9.1%), and VT remained inducible in 1 dog (9.1%), although this was focal midmyocardial VT only. In the seven dogs with VT of myocardial origin, six (85.6%) remained inducible with clonidine, whereas one dog (14.4%) had only nonsustained VT after clonidine. Of the six dogs, UK 14,304 blocked VT induction in four (66.6%) and rendered VT nonsustained in one (16.7%), and VT remained inducible in one dog (16.7%). In four dogs with VT of myocardial origin, VT remained inducible. In the eight control dogs that were given saline, focal Purkinje VT was repeatedly inducible. Pharmacological stimulation of postjunctional alpha(2)-adrenoceptors on Purkinje fibers may selectively prevent induction of VT of Purkinje fiber origin in the ischemic canine ventricle.
Collapse
Affiliation(s)
- D O Arnar
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa College of Medicine and Veterans Administration Medical Center, Iowa City, Iowa 52242, USA
| | | | | | | |
Collapse
|
46
|
Farré J, Cabrera JA, Romero J, Rubio JM. Therapeutic decision tree for patients with sustained ventricular tachyarrhythmias or aborted cardiac arrest: a critical review of the Antiarrhythmics Versus Implantable Defibrillator trial and the Canadian Implantable Defibrillator Study. Am J Cardiol 2000; 86:44K-51K. [PMID: 11084100 DOI: 10.1016/s0002-9149(00)01291-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Antiarrhythmic drugs, mainly amiodarone and sotalol, radiofrequency catheter ablation, and the implantable cardioverter defibrillator (ICD) are the 3 therapeutic options in patients with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Idiopathic VT, incessant VT, frequently recurring, hemodynamically stable VT, and VT based on bundle branch reentry, are candidates for radiofrequency catheter ablation. Patients with high-risk ventricular tachyarrhythmias should receive ICDs as initial therapy. Two studies, the Antiarrhythmics Versus Implantable Defibrillator trial (AVID) and the Canadian Implantable Defibrillator Study (CIDS) have tried to approach the problem of these high-risk ventricular tachyarrhythmias. Although at 3 years, the ICD in AVID demonstrated a significant relative risk reduction over amiodarone of 31.5%, CIDS could not duplicate this finding. At 3 years, the relative risk reduction conferred by the ICD over amiodarone in CIDS was only 13.7%. A careful analysis of both studies suggests that CIDS was insufficiently powered to demonstrate statistically significant benefits similar to those shown by AVID, and furthermore, seemed to include an undetermined number of low-risk VT patients. The problem in the CIDS trial in this regard was the recruitment of patients in whom the inclusion criteria were met by the arrhythmias induced during the electrophysiology stimulation study, but which did not exist in real life. In addition CIDS included 14% of patients with (1) undocumented syncope and inducible monomorphic sustained VT; or (2) long runs of spontaneous nonsustained VT. Under these circumstances, the therapeutic implications of AVID remain unchallenged.
Collapse
Affiliation(s)
- J Farré
- Department of Cardiology, Fundación Jiménez Díaz, Madrid, Spain
| | | | | | | |
Collapse
|
47
|
Abstract
Idiopathic ventricular tachycardia (VT) is characterized by two predominant forms. The most common form originates from the right ventricular outflow tract and presents as repetitive monomorphic VT or exercise-induced VT. The tachycardia is adenosine sensitive and is thought to be because of cAMP-mediated triggered activity. The other major form of idiopathic VT is owing to verapamil-sensitive intrafascicular re-entrant tachycardia, which most often originates in the region of the left posterior fascicle. Both forms of idiopathic VT can be readily treated with radiofrequency catheter ablation.
Collapse
Affiliation(s)
- B B Lerman
- Department of Medicine, New York Hospital-Cornell University Medical Center, New York, USA.
| | | | | | | | | |
Collapse
|
48
|
Chalvidan T, Cellarier G, Deharo JC, Colin R, Savon N, Barra N, Peyre JP, Djiane P. His-Purkinje system reentry as a proarrhythmic effect of flecainide. Pacing Clin Electrophysiol 2000; 23:530-3. [PMID: 10793448 DOI: 10.1111/j.1540-8159.2000.tb00841.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a case of tachycardia due to reentry within the His-Purkinje system (HPS) occurring after introduction of flecainide. The patient presented with a mild mitral regurgitation and normal left ventricular function. He had incomplete left bundle branch block with left-axis deviation. At the electrophysiology study, a prolonged HV interval was observed at baseline, and the tachycardia could be reproduced after ajmaline infusion. Six months after interruption of flecainide, the patient remains free of arrhythmia recurrence. The authors emphasize that proarrhythmic effects of flecainide may include reentry within the HPS in patients with underlying HPS disease.
Collapse
Affiliation(s)
- T Chalvidan
- Service de Cardiologie, Hôpital Sainte-Marguerite, CHU Marseille, France
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Prakash VS, Chen YJ, Yu WC, Tai CT, Chen SA. Does one mechanism explain the tachycardias? Pacing Clin Electrophysiol 1999; 22:811-3. [PMID: 10353142 DOI: 10.1111/j.1540-8159.1999.tb00547.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- V S Prakash
- Department of Medicine, National Yang-Ming University, School of Medicine, Taiwan, R.O.C
| | | | | | | | | |
Collapse
|
50
|
Nogami A, Naito S, Tada H, Oshima S, Taniguchi K, Aonuma K, Iesaka Y. Verapamil-sensitive left anterior fascicular ventricular tachycardia: results of radiofrequency ablation in six patients. J Cardiovasc Electrophysiol 1998; 9:1269-78. [PMID: 9869526 DOI: 10.1111/j.1540-8167.1998.tb00102.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Verapamil-sensitive left ventricular tachycardia (VT) with a right bundle branch block (RBBB) configuration and left-axis deviation has been demonstrated to arise from the left posterior fascicle, and can be cured by catheter ablation guided by Purkinje potentials. Verapamil-sensitive VT with an RBBB configuration and right-axis deviation is rare, and may originate in the left anterior fascicle. METHODS AND RESULTS Six patients (five men and one woman, mean age 54+/-15 years) with a history of sustained VT with an RBBB configuration and right-axis deviation underwent electrophysiologic study and radiofrequency (RF) ablation. VT was slowed and terminated by intravenous administration of verapamil in all six patients. Left ventricular endocardial mapping during VT identified the earliest ventricular activation in the anterolateral wall of the left ventricle in all patients. RF current delivered to this site suppressed the VT in three patients (ablation at the VT exit). The fused Purkinje potential was recorded at that site, and preceded the QRS complex by 35, 30, and 20 msec, with pace mapping showing an optimal match between the paced rhythm and the clinical VT. In the remaining three patients, RF catheter ablation at the site of the earliest ventricular activation was unsuccessful. In these three patients, Purkinje potential was recorded in the diastolic phase during VT at the mid-anterior left ventricular septum. The Purkinje potential preceded the QRS during VT by 66, 56, and 63 msec, and catheter ablation at these sites was successful (ablation at the zone of slow conduction). During 19 to 46 months of follow-up (mean 32+/-9 months), one patient in the group of ablation at the VT exit had sustained VT with a left bundle branch block configuration and an inferior axis, and one patient in the group of ablation at the zone of slow conduction experienced typical idiopathic VT with an RBBB configuration and left-axis deviation. CONCLUSION Verapamil-sensitive VT with an RBBB configuration and right-axis deviation originates close to the anterior fascicle. RF catheter ablation can be performed successfully from the VT exit site or the zone of slow conduction where the Purkinje potential was recorded in the diastolic phase.
Collapse
Affiliation(s)
- A Nogami
- Clinical Electrophysiology Laboratory, Gunma Prefectural Cardiovascular Center, Maebashi, Japan.
| | | | | | | | | | | | | |
Collapse
|