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

다국어 초록 (Multilingual 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.

참고문헌 (Reference)

1 Doppalapudi H, "Ventricular tachycardia originating from the posterior papillary muscle in the left ventricle: a distinct clinical syndrome" 1 : 23-29, 2008

2 Good E, "Ventricular arrhythmias originating from a papillary muscle in patients without prior infarction: a comparison with fascicular arrhythmias" 5 : 1530-1537, 2008

3 Wen MS, "Successful radiofrequency ablation of idiopathic left ventricular tachycardia at a site away from the tachycardia exit" 30 : 1024-1031, 1997

4 Lee KT, "Successful catheter ablation of idiopathic left ventricular tachycardia during sinus rhythm" 115 : 74-77, 2007

5 Schilling RJ, "Simultaneous endocardial mapping in the human left ventricle using a noncontact catheter: comparison of contact and reconstructed electrograms during sinus rhythm" 98 : 887-898, 1998

6 Tsuchiya T, "Significance of late diastolic potential preceding Purkinje potential in verapamil-sensitive idiopathic left ventricular tachycardia" 99 : 2408-2413, 1999

7 Pak HN, "Role of the posterior papillary muscle and Purkinje potentials in the mechanism of ventricular fibrillation in open chest dogs and swine: Effects of catheter ablation" 17 : 777-783, 200607

8 김영훈, "Role of papillary muscle in the generation and maintenance of reentry during ventricular tachycardia and fibrillation in isolated swine right ventricle" LIPPINCOTT WILLIAMS & WILKINS 100 : 1450-1459, 199909

9 Belhassen B, "Response of recurrent sustained ventricular tachycardia to verapamil" 46 : 679-682, 1981

10 Swartz JF, "Radiofrequency endocardial catheter ablation of accessory atrioventricular pathway atrial insertion sites" 87 : 487-499, 1993

11 Nakagawa H, "Radiofrequency catheter ablation of idiopathic left ventricular tachycardia guided by a Purkinje potential" 88 : 2607-2617, 1993

12 Betts TR, "Radiofrequency ablation of idiopathic left ventricular tachycardia at the site of earliest activation as determined by noncontact mapping" 11 : 1094-1101, 2000

13 Veenstra RD, "Purkinje and ventricular activation sequences of canine papillary muscle. Effects of quinidine and calcium on the Purkinje-ventricular conduction delay" 54 : 500-515, 1984

14 Myerburg RJ, "Physiology of canine intraventricular conduction and endocardial excitation" 30 : 217-243, 1972

15 김영훈, "Papillary muscle hypothesis of idiopathic left ventricular tachycardia" ELSEVIER SCIENCE INC 37 (37): 1475-1476, 200104

16 Friedman PA, "Noncontact mapping to guide ablation of right ventricular outflow tract tachycardia" 39 : 1808-1812, 2002

17 Chen M, "Non-contact mapping and linear ablation of the left posterior fascicle during sinus rhythm in the treatment of idiopathic left ventricular tachycardia" 7 : 138-144, 2005

18 Haïssaguerre M, "Mapping and ablation of idiopathic ventricular fibrillation" 106 : 962-967, 2002

19 Ma FS, "Left posterior fascicular block: a new endpoint of ablation for verapamil-sensitive idiopathic ventricular tachycardia" 119 : 367-372, 2006

20 Blanchard SM, "Interpolating unipolar epicardial potentials from electrodes separated by increasing distances" 12 : 1938-1955, 1989

21 Higa S, "Focal atrial tachycardia: new insight from noncontact mapping and catheter ablation" 109 : 84-91, 2004

22 Okumura K, "Entrainment of idiopathic ventricular tachycardia of left ventricular origin with evidence for reentry with an area of slow conduction and effect of verapamil" 62 : 727-732, 1988

23 Sra J, "Endocardial noncontact activation mapping of idiopathic left ventricular tachycardia" 11 : 1409-1412, 2000

24 Yamada T, "Electrocardiographic and electrophysiological characteristics in idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle: relevance for catheter ablation" 3 : 324-331, 2010

25 Ouyang F, "Electroanatomic substrate of idiopathic left ventricular tachycardia: unidirectional block and macroreentry within the purkinje network" 105 : 462-469, 2002

26 Pil Sang Song, "Electrical Storms in Patients with an Implantable Cardioverter Defibrillator" 연세대학교의과대학 52 (52): 26-32, 2011

27 Tsuchiya T, "Effects of verapamil and lidocaine on two components of the re-entry circuit of verapamil-senstitive idiopathic left ventricular tachycardia" 37 : 1415-1421, 2001

28 Joyner RW, "Effects of stimulation frequency on Purkinje-ventricular conduction" 591 : 38-50, 1990

29 Maruyama M, "Demonstration of the reentrant circuit of verapamil-sensitive idiopathic left ventricular tachycardia: direct evidence for macroreentry as the underlying mechanism" 12 : 968-972, 2001

30 Nogami A, "Demonstration of diastolic and presystolic Purkinje potentials as critical potentials in a macroreentry circuit of verapamil-sensitive idiopathic left ventricular tachycardia" 36 : 811-823, 2000

31 Pak HN, "Catheter ablation of ventricular fibrillation in rabbit ventricles treated with beta-blockers" 108 : 3149-3156, 2003

32 Massing GK, "Anatomical configuration of the His bundle and bundle branches in the human heart" 53 : 609-621, 1976