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Nogami A, Komatsu Y, Talib AK, Phanthawimol W, Naeemah QJ, Haruna T, Morishima I. Purkinje-Related Ventricular Tachycardia and Ventricular Fibrillation: Solved and Unsolved Questions. JACC Clin Electrophysiol 2023; 9:2172-2196. [PMID: 37498247 DOI: 10.1016/j.jacep.2023.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/05/2023] [Accepted: 05/24/2023] [Indexed: 07/28/2023]
Abstract
Of the monomorphic ventricular tachycardias, there are 4 specific tachycardias related to the Purkinje system: 1) idiopathic verapamil-sensitive fascicular ventricular tachycardia (FVT); 2) non-re-entrant FVT; 3) bundle branch re-entry and interfascicular re-entry; and 4) Purkinje-mediated VT in structural heart disease. Verapamil-sensitive FVT is classified into 4 types according to the location of the circuit: 1) left posterior type; 2) left anterior type; 3) left upper septal type;and 4) reverse type. And, in the left anterior and posterior types, there are septal and papillary muscle subtypes. Although macro-re-entry has been reported to be the mechanism underlying verapamil-sensitive FVT, recording the entire circuit is challenging. One possible reason is that the Purkinje-muscle junction may penetrate the myocardial layer as a part of the circuit. The Purkinje network may thus play an important role in the initiation and maintenance of ventricular fibrillation. Further, it has been reported that the development and the abnormalities of the Purkinje system are associated with the arrhythmogenesis of ventricular fibrillation. Furthermore, it has been reported that catheter ablation of trigger ventricular premature complexes, and/or "de-networking" of the Purkinje system, can be used as electrical bailout therapy. There is a hypothesis that the intramural Purkinje system is involved in the generation of J waves. Nevertheless, as there are still unresolved issues that must be debated and accurately analyzed, this review aims to discuss the solved and unsolved questions related to Purkinje-related arrhythmias.
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Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan; Institute of Arrhythmia, Tokyo Heart Rhythm Hospital, Tokyo, Japan.
| | - Yuki Komatsu
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Ahmed Karim Talib
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan; Faculty of Medicine, University of Kufa, Najaf, Iraq
| | - Wipat Phanthawimol
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan; Cardiac Electrophysiology Unit, Division of Cardiology, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | - Qasim J Naeemah
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan; Faculty of Medicine, University of Kufa, Najaf, Iraq
| | - Tetsuya Haruna
- Cardiovascular Center, Medical Research Institute Kitano Hospital, Osaka, Japan
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
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Wang C, Ju W, Chen H, Yang G, Zhang F, Zhou L, Chen M. The clinical and electrophysiological characteristics of nonsustained repetitive monomorphic ventricular tachycardia from the left His-Purkinje system. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:1149-1155. [PMID: 32886352 DOI: 10.1111/pace.14055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 08/14/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Repetitive monomorphic ventricular tachycardia (RMVT) arising from the left His-Purkinje system can occasionally be encountered during clinical practice. We describe eight cases as a unique entity in this study to characterize the clinical and electrophysiological features of the patients. METHODS Eight patients with frequent palpitation (five men with median age of 28 years) were included in the study from January 2003 to July 2018. Twelve-lead ECG (Electrocardiogram), Holter, and echocardiographic tests were performed after medical history interrogations and physical examinations. Antiarrhythmic drug therapy was essential to all patients, and catheter ablation was attempted if the patients could not tolerate or were not responsive to drug therapy. RESULTS No patients had a history of syncope and a family history of sudden cardiac death. ECGrecording was characterized by frequent ventricular extrasystoles, ventricular couplets, and salvos of nonsustained VT competitive with sinus rhythm. The QRS morphology of ectopic beats was in the right bundle branch block pattern with severe left axis deviation. The width of the QRS complex from ECG was 135 ms (120-140) during ventricular tachycardia. Verapamil had no effect on all VT individuals. Enlargement of the left ventricle was found in two patients. Four out of six cases were successful with catheter ablation treatment. CONCLUSION RMVT arising from the left His-Purkinje system is a special arrhythmic and nonverapamil-sensitive entity. The electrophysiological mechanism of this treatment appears to be focal firing, which is amendable to catheter ablation in symptomatic and high-burden patients.
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Affiliation(s)
- Cheng Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Fengxiang Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Lei Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
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Talib AK, Nogami A, Morishima I, Oginosawa Y, Kurosaki K, Kowase S, Komatsu Y, Kuroki K, Igarashi M, Sekiguchi Y, Aonuma K. Non-Reentrant Fascicular Tachycardia. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.004177. [DOI: 10.1161/circep.116.004177] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 08/23/2016] [Indexed: 11/16/2022]
Abstract
Background—
The most common form of idiopathic Purkinje-related ventricular tachycardia (VT) is the reentrant type. We describe the clinical and electrophysiological characteristics of focal non-reentrant fascicular tachycardia.
Methods and Results—
Among 530 idiopathic VT patients who were referred for ablation, we identified 15 (2.8%) with non-reentrant fascicular tachycardia (11 men, 45±21 years). Sinus rhythm ECG showed normal conduction intervals with a His–ventricular interval of 41±4 ms. All patients had monomorphic VT (cycle length: 337±88 ms) with a relatively narrow QRS (123±12 ms), and they did not respond to verapamil during the initial presentation. VT exhibited right bundle-branch block/superior axis configuration in 11 patients (73%) and inferior axis in 3 (20%). In 1 patient (7%), VT exhibited left bundle-branch block/superior axis configuration. During ablation, spontaneous VT occurred in 3 patients (20%) and nonentraintable VT or identical premature ventricular complex was induced in 9 (60%). A high-frequency presystolic Purkinje potential was recorded during VT/premature ventricular complex, preceding the QRS by 25±16 ms. VT recurrence was observed in 4 patients (27%), and among them, 3 underwent pacemap-guided ablation during the first session. A second ablation with activation mapping guidance eliminated the VT during the 88±8-month follow-up.
Conclusions—
Among idiopathic VT cases referred for ablation, 2.8% were focal non-reentrant fascicular tachycardia, which had distinct clinical characteristics and usually originated from the left posterior fascicle, and less commonly from the left anterior fascicle and right ventricular Purkinje network. Catheter ablation is effective, whereas pacemap-guided approach is less efficacious.
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Affiliation(s)
- Ahmed Karim Talib
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Akihiko Nogami
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Itsuro Morishima
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Yasushi Oginosawa
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Kenji Kurosaki
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Shinya Kowase
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Yuki Komatsu
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Kenji Kuroki
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Miyako Igarashi
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Yukio Sekiguchi
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
| | - Kazutaka Aonuma
- From the Cardiovascular Division, Faculty of Medicine, Tsukuba University, Japan (A.K.T., A.N., K.K., M.I., Y.S., K.A.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); and Department of Heart Rhythm Management, Yokohama Rosai Hospital, Kanagawa, Japan (Y.O., S.K., Y.K., K.K.)
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