Nonreentrant proximal fascicular ventricular tachycardia, with normal QRS duration and normal axis, originating from a region remote from the His bundle

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Nonreentrant proximal fascicular ventricular tachycardia, with normal QRS duration and normal axis, originating from a region remote from the His bundle Shota Ikeda, MD, Kenji Kurosaki, MD, PhD, Yuki Komatsu, MD, Shinya Kowase, MD, Akihiko Nogami, MD, PhD HeartRhythm Case Reports Volume 4, Issue 7, Pages 281-284 (July 2018) DOI: 10.1016/j.hrcr.2018.03.007 Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 1 The morphologies of each ventricular tachycardia (VT; VT1–4). A clinical VT (VT1) with a normal QRS duration and a normal axis is observed at baseline. (* indicates right ventricular pacing.) VT2 with a right bundle branch block (RBBB) and an inferior axis is evident after radiofrequency (RF) energy application at site A (described in Figure 3). VT3 with an RBBB and a superior axis is observed after RF energy application at site B (described in Figure 3). VT4 with an RBBB and a right axis deviation is evident after RF energy application at site C (described in Figure 3). HeartRhythm Case Reports 2018 4, 281-284DOI: (10.1016/j.hrcr.2018.03.007) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 2 Radiofrequency (RF) energy application to the left aspect of the basal ventricular septum. A: The local potential in the left aspect of the basal intraventricular septum preceded the QRS onset by 40 ms. A His potential, preceding QRS onset by 34 ms, is evident at the His electrode. The His potential disappears just after the ablation at site A. B: The QRS morphology gradually changes into a right bundle branch block (RBBB) pattern during RF energy application at site A. HeartRhythm Case Reports 2018 4, 281-284DOI: (10.1016/j.hrcr.2018.03.007) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 3 The site where the tachycardia was eliminated and a description of the assumed mechanism of the QRS morphology change. A: The CARTO image indicates the point of each ablation (sites A–D). B: (Site D) Fluoroscopy shows the ablation catheter at the basal anterior wall. C: A Purkinje potential at the basal anterior wall, preceding the QRS by 68 ms, is the earliest in the session. D–G: Assumed mechanism of QRS morphology changes, illustrating the assumed correlation between the ablation points and the tachycardia origin. ABL = ablation catheter; His-RV = catheter at the His bundle region and right ventricular apex; HRA = catheter at the high right atrium; LAO = left anterior oblique; RAO = right anterior oblique. HeartRhythm Case Reports 2018 4, 281-284DOI: (10.1016/j.hrcr.2018.03.007) Copyright © 2018 Heart Rhythm Society Terms and Conditions