Recurrent polymorphic ventricular tachycardia initiated by Purkinje ectopy in a patient with cardiac sarcoidosis Faisal Matto, MD, Mohsan Chaudhry, MD,

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Recurrent polymorphic ventricular tachycardia initiated by Purkinje ectopy in a patient with cardiac sarcoidosis Faisal Matto, MD, Mohsan Chaudhry, MD, Mahi Ashwath, MD, Akhil Parashar, MD, Alexander Mazur, MD HeartRhythm Case Reports Volume 5, Issue 7, Pages 363-366 (July 2019) DOI: 10.1016/j.hrcr.2019.03.012 Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 1 A: Telemetry tracing shows an episode of sustained polymorphic ventricular tachycardia triggered by a narrow complex premature ventricular contraction (PVC) (asterisk). B: Twelve-lead electrocardiogram shows frequent narrow complex PVCs (asterisks) of right bundle branch/superior axis morphology with variable coupling intervals and some alterations in the QRS morphology. HeartRhythm Case Reports 2019 5, 363-366DOI: (10.1016/j.hrcr.2019.03.012) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 2 Cardiac magnetic resonance images. A, B: Short-axis slices show resting myocardial perfusion abnormalities involving epicardial basal anterior septum, subendocardial inferior septum, and subendocardial anterior wall (arrowheads). C, D: Delayed enhancement sequences show an extensive area of late gadolinium enhancement with the spared endocardial borders involving basal and mid segments of the interventricular septum (arrows). HeartRhythm Case Reports 2019 5, 363-366DOI: (10.1016/j.hrcr.2019.03.012) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 3 A: Ultrasound-based (CARTO-Sound, Biosense Webster, Irvine, CA) geometries of the left (LV) and right (RV) ventricles. Red spheres represent ablation lesions in the basal-mid LV septum. B: Surface electrocardiogram (ECG) leads II, aVF, V1, and V6 and endocardial electrograms from the ablation (ABL), coronary sinus (CS), His, and right ventricular (RVA) catheters. A sinus beat followed by 2 premature ventricular contractions (PVCs). Note high-frequency Purkinje potentials that precede the sinus beat (arrow) and PVCs (asterisks) with variable Purkinje-to-ventricle conduction times during PVCs. The latter may indicate different exit sites and can potentially explain variable coupling intervals as well as some alterations in the PVC QRS morphology noted on the surface ECG (Figure 1B). AL = anterolateral papillary muscle; AV = aortic valve; MVA = mitral valve annulus; PM = posteromedial papillary muscle. HeartRhythm Case Reports 2019 5, 363-366DOI: (10.1016/j.hrcr.2019.03.012) Copyright © 2019 Heart Rhythm Society Terms and Conditions