Mechanisms of Posterior Fascicular Tachycardia

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Date of download: 6/25/2016 Copyright © The American College of Cardiology. All rights reserved. From: Mechanism, localization and cure of atrial arrhythmias.

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Presentation transcript:

Mechanisms of Posterior Fascicular Tachycardia by Qiang Liu, Michael Shehata, Ruhong Jiang, Lu Yu, Jun Zhu, Ashkan Ehdaie, Eugenio Cingolani, Sumeet S. Chugh, Chenyang Jiang, and Xunzhang Wang Circ Arrhythm Electrophysiol Volume 9(9):e003754 September 13, 2016 Copyright © American Heart Association, Inc. All rights reserved.

A, Surface ECG of tachycardia showed wide QRS complex (QRS duration=140 ms) with a right bundle branch block pattern and left-axis deviation. A, Surface ECG of tachycardia showed wide QRS complex (QRS duration=140 ms) with a right bundle branch block pattern and left-axis deviation. B, During sinus rhythm (left), A–H and H–V intervals were 57 and 55 ms, respectively. P2 was recorded with an antegrade conduction sequence from proximal to distal multielectrode catheter (MEC). The ventricular potentials at the mid MEC were earlier than proximal and distal ventricular potentials. During tachycardia (right), the H–V interval was −30 ms. P1 and P2 were recorded with opposite conduction sequences with P1 activated antegradely, and P2 activated retrogradely. P1 transition to P2 activation occurred toward the distal MEC. C, Right and left anterior oblique fluoroscopic images of catheter positions. The 20 pole MEC was positioned at the left septal ventricle via a retrograde aortic approach. CS indicates coronary sinus electrogram; HIS, His bundle electrogram; His, His bundle; LAF, left anterior fascicle; LAO, left anterior oblique; LPF, left posterior fascicle; LV, left ventricular electrogram; RAO, right anterior oblique; RB, right bundle; and RV, right ventricular electrogram. Qiang Liu et al. Circ Arrhythm Electrophysiol. 2016;9:e003754 Copyright © American Heart Association, Inc. All rights reserved.

A, Ventricular programmed stimulation from the septal right ventricle (S1S2, 400/300 ms) to induce FVT. During S1 stimulation, P1 was recorded with an antegrade conduction sequence and a S1–P1 interval of 255 ms. A, Ventricular programmed stimulation from the septal right ventricle (S1S2, 400/300 ms) to induce FVT. During S1 stimulation, P1 was recorded with an antegrade conduction sequence and a S1–P1 interval of 255 ms. After the S2 stimulus delivery, the S2–P1 interval increased to 320 ms with induction of FVT. A schematic diagram shows the sequence of FVT induction. The site of possible slow conduction (wavy line) may be located at the proximal P1 region. P1 is the antegrade limb of the reentry circuit and activation of proximal P1 can occur either from retrograde conduction of P2 via the ventricular myocardium (solid arrow) or directly from ventricular myocardium at the distal MEC (open arrow). B, Premature ventricular contractions (PVC) introduced from the midright ventricular septum during tachycardia. A PVC advanced the immediate septal ventricle (V*) and His bundle via the right bundle brunch retrogradely, without alteration of the immediate P1 or P2. The subsequent P1 was advanced by 10 ms and the following P2 and QRS were advanced sequentially. C and D, Atrial overdrive pacing from proximal CS catheter at a cycle length of 300 ms during FVT. C, Progressive antegrade capture of P2 and the Purkinje system was observed with narrowing of the surface QRS morphology. At beat 4, the septal ventricle (V*) at the mid-MEC was advanced by antegrade conduction of P2 without advancement of the ventricular potential at the distal MEC, and the subsequent P1 in beat 5 was advanced. D, The earliest ventricular activation at beat 7 activated by the antegrade conduction of P2 was observed at the mid-MEC. The subsequent P1 (beat 8) initiated FVT with retrograde P2 conduction. Schematic diagrams depict conduction patterns during atrial overdrive pacing. C shows that the LPB is gradually activated antegradely by atrial pacing and that each P1 activation follows previous ventricular activation. D depicts the initiation of tachycardia with the last paced beat 7 activating P1 antegradely (beat 8) and re-entry begins either with retrograde conduction of P2 via the ventricular myocardium (solid arrow) or directly from ventricular myocardium at the distal MEC (open arrow). AVN indicates atrioventricular node; CS, coronary sinus electrogram; FVT, fascicular ventricular tachycardia; HIS, His bundle electrogram; His, His bundle; LV, left ventricular electrogram; LAF, left anterior fascicle; LPF, left posterior fascicle; MEC, multielectrode catheter; RB, right bundle; and RV, right ventricular electrogram. Qiang Liu et al. Circ Arrhythm Electrophysiol. 2016;9:e003754 Copyright © American Heart Association, Inc. All rights reserved.

A, During sinus rhythm (left), A–H and H–V intervals were 58 and 60 ms, respectively. A, During sinus rhythm (left), A–H and H–V intervals were 58 and 60 ms, respectively. P2 was recorded with an antegrade conduction sequence from proximal to distal MEC. The earliest ventricular potential was located at the distal MEC. During tachycardia (right), the H–V interval was −20 ms with 2:1 retrograde conduction. P1 and P2 were recorded with opposite conduction sequences with P1 activated antegradely and P2 activated retrogradely. P1 transition to P2 activation occurred toward the mid-distal MEC, simultaneous with the earliest recorded ventricular potential. B, During tachycardia, radiofrequency ablation was delivered at the location where the distal P1 fused with P2 and ventricular myocardium. After radiofrequency delivery, tachycardia was terminated with disconnection of the distal P1 potentials. Schematic diagrams show the potential reentrant circuit (left) and the termination of the tachycardia with antegrade block of distal P1 after ablation (right). C, After cessation of ablation, a delayed antegrade conduction of P1 was observed during either programmed ventricular pacing or sinus rhythm. Schematic diagrams show the P1 was antegradely activated during RVA pacing (left) and sinus rhythm (right). D, During ablation at the level of the proximal P1 potentials, automaticity arising from the P2 or local ventricle was noted with subsequent elimination of the P1 potentials. Schematic diagram shows the antegrade and retrograde block of the P1 fiber. ABL indicates ablation catheter; AVN, atrioventricular node; CS, coronary sinus electrogram; HIS, His bundle electrogram; His, His bundle; LAF, left anterior fascicle; LPF, left posterior fascicle; LV, left ventricular electrogram; MEC, multielectrode catheter; RB, right bundle; and RV, right ventricular electrogram. Qiang Liu et al. Circ Arrhythm Electrophysiol. 2016;9:e003754 Copyright © American Heart Association, Inc. All rights reserved.

A, Surface ECG of tachycardia showed wide QRS complex (QRS duration=125 ms) with a right bundle branch block pattern and left-axis deviation. A, Surface ECG of tachycardia showed wide QRS complex (QRS duration=125 ms) with a right bundle branch block pattern and left-axis deviation. B, During sinus rhythm (left), A–H and H–V intervals were 75 and 60 ms, respectively. P2 was recorded with an antegrade conduction sequence from proximal to distal MEC. The earliest ventricular potential was located at the mid-distal MEC. During tachycardia (right), the H–V interval was −5 ms with 1:1 retrograde conduction. P2 potentials were recorded with a retrograde conduction sequence from mid-distal to proximal MEC. C, Right and left anterior oblique fluoroscopic images of catheter positions. D, Premature ventricular contractions (PVC) introduced from the midright ventricular septum during tachycardia. A PVC (Induced by the second stimulus) advanced the immediate high septal ventricle (V*) without alteration of the immediate P2. The subsequent P2 is advanced by 15 ms, and the following QRS was advanced sequentially. Schematic diagram in the right depicts the potential reentrant circuit of the tachycardia. E, Overdrive pacing from the right midseptal ventricle during tachycardia at cycle lengths of 305, 300, 290, and 270 ms. Surface ECG demonstrates entrainment of tachycardia with progressive fusion of QRS morphology during decreasing pacing cycle length. F, Theoretically, ablation targeting the distal or proximal LPF away from the optimal target may result in different changes in QRS morphology during tachycardia. Schematic diagram shows the potential mechanisms. Left, the reentrant circuit may involve both the right bundle branch and the left anterior fascicle after ablating the distal part of the LPF away from the target, a narrow QRS morphology may be observed with positive H–V interval; Right, a wider QRS morphology with left-axis deviation and more negative H–V interval may emerge after ablating the proximal part of the LPF away from the target because of loss of antegrade conduction from the right bundle branch and left anterior fascicle. AVN indicates atrioventricular node; CS, coronary sinus electrogram; HIS, His bundle electrogram; His, His bundle; LAF, left anterior fascicle; LAO, left anterior oblique; LPF, left posterior fascicle; LV, left ventricular electrogram; MEC, multielectrode catheter; RAO, right anterior oblique; RB, right bundle; RV, right ventricular electrogram; and SS, overdrive pacing cycle length. Qiang Liu et al. Circ Arrhythm Electrophysiol. 2016;9:e003754 Copyright © American Heart Association, Inc. All rights reserved.