Yonsei Med J.  2012 Mar;53(2):279-288. 10.3349/ymj.2012.53.2.279.

Electroanatomical Characteristics of Idiopathic Left Ventricular Tachycardia and Optimal Ablation Target during Sinus Rhythm: Significance of Preferential Conduction through Purkinje Fibers

• Park J
• Kim YH
• Hwang C
• Pak HN

• KMID: 1120193
• DOI: http://doi.org/10.3349/ymj.2012.53.2.279

Abstract

PURPOSE
We hypothesized that Purkinje potential and their preferential conduction to the left ventricle (LV) posteroseptum during sinus rhythm (SR) are part of reentrant circuits of idiopathic left ventricular tachycardia (ILVT) and reentry anchors to papillary muscle.
MATERIALS AND METHODS
In 14 patients with ILVT (11 men, mean age 31.5+/-11.1 years), we compared Purkinje potential and preferential conduction during SR with VT by non-contact mapping (NCM). If clear Purkinje potential(SR) was observed in the LV posteroseptum and the earliest activation site (EA) of preferential conduction at SR (EASR) was well matched with that of VT (EAVT), EASR was targeted for radiofrequency catheter ablation (RFCA). Also, the anatomical locations of successful ablation sites were evaluated by echocardiography in five additional patients.
RESULTS
1) All induced VTs exhibited clear Purkinje potential(VT) and preferential conduction in the LV posteroseptum. The Purkinje potential(VT) and EAVT was within 5.8+/-8.2 mm of EASR. However, the breakout sites of VT were separated by 30.2+/-12.6 mm from EAVT to the apical side. 2) Purkinje potential(SR) demonstrated a reversed polarity to Purkinje potential(VT), and the interval of Purkinje potential(SR)-QRS was longer than the interval of Purkinje potential(VT)-QRS (p<0.02) 3) RFCA targeting EASR eliminated VT in all patients without recurrence within 23.3+/-7.5 months, and the successful ablation site was discovered at the base of papillary muscle in the five additional (100%) patients.
CONCLUSION
NCM-guided localization of EASR with Purkinje potential(SR) matches well with EAVT with Purkinje potential(VT) and provides an effective target for RFCA, potentially at the base of papillary muscle in patients with ILVT.

Keyword

Idiopathic left ventricular tachycardia; catheter ablation; non-contact map; Purkinje

MeSH Terms

Adult
Catheter Ablation
Electrophysiology
Female
Humans
Male
Purkinje Fibers/*physiology
Tachycardia, Ventricular/*physiopathology/surgery
Ventricular Dysfunction, Left/*physiopathology/surgery
Young Adult

Figure

• 

  Fig. 1 Purkinje potential (arrows) during sinus rhythm and a ventricular premature beat with the same QRS morphology as ILVT. A sharp fractionated potential precedes the local ventricular potentials in the ablation catheter recordings (ABL). This Purkinje potential(SR) occurs later than the His potential (H), and the Purkinje potential(SR) to V interval (42 ms) is longer than Purkinje potential(VT) to the premature ventricular beat (37 ms). HRA and RVa stand for high right atrium and right ventricular apex. ds, distal; px, proximal. ILVT, idiopathic left ventricular tachycardia; ABL, ablation catheter; HRA, high right atrium; RVa, right ventricular apex.

• 

  Fig. 2 Virtual unipolar electrograms during sinus rhythm (A) and ILVT (B) recorded at the LV posteroseptal region where Purkinje potential were recorded. The location of the virtual electrogram cursor matches that seen in the non-contact mapping in Fig. 4. The small notches preceding the ventricular potentials are on the mid-septum, and their polarities are respectively reversed during sinus rhythm and ILVT. In B, the QS pattern in the apical septum and the Rs pattern in the basal septum suggest that conduction through the posterior fascicle goes from the apical side to the basal side during ILVT. ILVT, idiopathic left ventricular tachycardia; LV, left ventricle.

• 

  Fig. 3 Correlation curves (A and B) and a Bland-Altman analysis (C and D) showing the relationship between the contact and non-contact electrogram voltage amplitude (A and C) and time duration (B and D) in the LV. EGM, electrogram; LV, left ventricle; SD, standard deviation.

• 

  Fig. 4 Activation pattern of an ILVT. The activation map (A-F) reveals retrograde conduction through the conduction system that reenters at a more mid-septal region. This reentry wavefront begins in this area (EA) and exits to the LV apex with preferential conduction. The sites of the numbers on the non-contact mapping mark the locations of the virtual electrodes recorded in panels G and H with the corresponding numbers. (G) Virtual electrograms with a 16 Hz filter setting recorded from the LV posteroseptum. (H) A high pass filter setting of 32 Hz shows pre-systolic potentials (arrows) at the conjunctional area of the Purkinje potential(VT) and EA(VT). This patient had QRS morphology of VT as a right bundle branch block and right axis deviation (case #5 in Table 1). ILVT, idiopathic left ventricular tachycardia; LV, left ventricle; EA, earliest activation site.

• 

  Fig. 5 Activation pattern during sinus rhythm in a patient with ILVT. The activation map (A-F) reveals anterograde conduction through the conduction system, which exits at the LV posteroseptum and apex. The EASR is very close to EAVT (Fig. 4), and the exit sites were separated from each other (Fig. 4). G and H show the virtual unipolar electrograms of one beat in sinus rhythm and one in ventricular premature beat, recorded at the sites of the numbers on the non-contact mapping using 16 Hz and 32 Hz filter settings, respectively. The white, dotted circle stands for the potential location of papillary muscle estimated by comparing the left ventriculogram and non-contact map. ILVT, idiopathic left ventricular tachycardia; LV, left ventricle; EA, earliest activation site.

• 

  Fig. 6 Echocardiographic images (A, B, and C) show the relationship between posterior papillary muscle and the successful ablation site. These trans-thoracic echocardiographies were recorded during RFCA of ILVT, and the ablation catheter (white arrow) and decapolar catheter (white dotted arrow) were positioned in the LV. Lower panel: the ablation catheter is located close to posterior papillary muscle where the Purkinje and presystolic potentials were recorded. RFCA, radiofrequency catheter ablation; ILVT, idiopathic left ventricular tachycardia; LV, left ventricle; PM, papillary muscle.

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