Incessant bundle branch reentrant ventricular tachycardia in a patient with corrected transposition of the great arteries Ken Kato, MD, Daigo Yagishita,

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Presentation transcript:

Incessant bundle branch reentrant ventricular tachycardia in a patient with corrected transposition of the great arteries Ken Kato, MD, Daigo Yagishita, MD, Koichiro Ejima, MD, PhD, Tetsuyuki Manaka, MD, PhD, Morio Shoda, MD, PhD, Nobuhisa Hagiwara, MD, PhD HeartRhythm Case Reports Volume 1, Issue 6, Pages 434-438 (November 2015) DOI: 10.1016/j.hrcr.2015.05.009 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 A 69-year-old patient with congenitally corrected transposition of the great arteries presenting a wide QRS regular tachycardia. A: Wide QRS tachycardia accompanied by left bundle branch block morphology with a leftward axis, QRS duration of 139 ms, and cycle length of 462 ms. B, C: Sinus rhythm shows 2 discrete non-preexcited morphologies with an inferior axis and a superior axis. The QRS duration was 102 ms. D: A surface electrocardiogram after ablation shows a right bundle branch block pattern with a superior axis in sinus rhythm. E: Anatomy of the heart in a patient with congenitally corrected transposition of the great arteries obtained by contrast-enhanced computed tomography in the AP projection. The green chamber is the right atrium. The blue chambers are the right-sided anatomic left ventricle and pulmonary artery. The yellow chamber is the left atrium behind the other chambers. The pink chambers are the left-sided anatomic right ventricle and ascending aorta. F: Position of catheters at an electrophysiological study in the AP projection. G: Tachycardia circuit estimated by electrophysiological study. Ao = aorta; AP = anterior-posterior projection; HRA = high right atrium; LA = left atrium; LV = left ventricle; MA = posteroseptal mitral annulus; PA = pulmonary artery; PT = pulmonary trunk; RA = right atrium; RV = right ventricle. HeartRhythm Case Reports 2015 1, 434-438DOI: (10.1016/j.hrcr.2015.05.009) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 Atrial activation patterns during the wide QRS tachycardia and entrainment from the left ventricular apex. A: Wide QRS tachycardia with single morphology was observed, but there were 3 patterns of atrial activation sequence and cycle length. B: Ventriculoatrial dissociation occurred during wide QRS tachycardia on an intracardiac electrocardiogram. C: Ventriculoatrial dissociation was present during entrainment pacing from the left ventricular apex. D: Entrainment pacing at a cycle length of 420, 400, and 300 ms from the left ventricular apex shows progressive fusion. CL = cycle length; HRA = high right atrium; LAp = proximal left atrium; LAd = distal left atrium; LV = left ventricle; MA = posteroseptal mitral annulus; St = stimulation. HeartRhythm Case Reports 2015 1, 434-438DOI: (10.1016/j.hrcr.2015.05.009) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 Entrainment from the high right atrium and termination of the wide QRS tachycardia by ablating the left bundle branch. A: QRS morphology in the surface electrocardiogram did not change during entrainment pacing at a cycle length of 410 ms from the high right atrium. B: Left bundle branch potential was recorded at the earliest site of ventricular activation on ABLd electrodes, which preceded the onset of QRS by 40 ms. C: Radiofrequency ablation terminated the tachycardia with complete antegrade block in the left bundle branch. ABLd = bipolar electrogram of an ablation catheter; ABLUni = unipolar electrogram of an ablation catheter; HRA = high right atrium; LAd = distal left atrium; LAp = proximal left atrium; LV = left ventricle; MA = posteroseptal mitral annulus; RF = radiofrequency; St = stimulation. HeartRhythm Case Reports 2015 1, 434-438DOI: (10.1016/j.hrcr.2015.05.009) Copyright © 2015 Heart Rhythm Society Terms and Conditions