Upper septal transformation of verapamil-sensitive idiopathic left ventricular tachycardia during catheter ablation: Wolf in sheep׳s clothing? Girish.

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Upper septal transformation of verapamil-sensitive idiopathic left ventricular tachycardia during catheter ablation: Wolf in sheep׳s clothing? Girish M. Nair, MBBS, MSc, FRCPC, FHRS, Vinod Thomas, MD, Nik Stoyanov, MD, Pablo B. Nery, MD, Mouhannad M. Sadek, MD, FRCPC, Martin S. Green, MD, FRCPC HeartRhythm Case Reports Volume 2, Issue 1, Pages 101-106 (January 2016) DOI: 10.1016/j.hrcr.2015.11.011 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 Figure showing electrocardiogram in sinus rhythm (both preablation and postablation), left posterior fascicular idiopathic left ventricular tachycardia (LPF ILVT) and upper septal idiopathic left ventricular tachycardia (US ILVT). The preablation 12-lead electrocardiogram is within normal limits. HeartRhythm Case Reports 2016 2, 101-106DOI: (10.1016/j.hrcr.2015.11.011) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 A: An illustration of the currently postulated mechanism of left posterior fascicular idiopathic left ventricular tachycardia. B: An illustration of the possible mechanism of transformation of the left posterior fascicular variant to the upper septal idiopathic left ventricular tachycardia variant. C: A view of the interventricular septal aspect of the left ventricle showing the ablation lesion set (blue arrow; maroon dots), the location of the atrioventricular node, the proximal left bundle, and the anterior and posterior fascicles (white arrows; green dots). The ablation line extends along the entire width of the interventricular septum and was created in the midportion to avoid the proximal left bundle and atrioventricular node. HeartRhythm Case Reports 2016 2, 101-106DOI: (10.1016/j.hrcr.2015.11.011) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 A: This illustration shows the transition of the left posterior fascicular variant of idiopathic left ventricular tachycardia (ILVT) to upper septal ILVT during catheter ablation. The transition point has been marked with a blue dot. B: This illustration shows the octapolar catheter recording (labeled LIVS 1–8 in pairs) during upper septal ILVT. The octapolar catheter has been positioned along the left ventricular aspect of the interventricular septum (LIVS). The distal-most electrodes (LIVS 1,2) are positioned at the apex, and the proximal-most electrodes (LIVS 7,8) are at the level of the proximal left bundle. The Purkinje potential to the earliest surface QRS interval was 21 milliseconds (compared with 42 milliseconds during sinus rhythm) Purkinje potentials are indicated by the blue arrows. HeartRhythm Case Reports 2016 2, 101-106DOI: (10.1016/j.hrcr.2015.11.011) Copyright © 2016 Heart Rhythm Society Terms and Conditions