Circulation, Vol 79, 256-270, Copyright © 1989 by American Heart Association
J Caceres, M Jazayeri, J McKinnie, B Avitall, ST Denker, P Tchou and M Akhtar
The incidence of sustained bundle branch reentrant (BBR) tachycardia as a
clinical or induced arrhythmia or both continues to be underreported. At
our institution, BBR has been the underlying mechanism of sustained
monomorphic ventricular tachycardia in approximately 6% of patients,
whereas mechanisms unrelated to BBR were the cause in the rest. Data
gathered from 20 consecutive patients showed electrophysiologic
characteristics that suggest this possibility. These include induction of
sustained monomorphic tachycardia with typical left or right bundle branch
block morphology or both and atrioventricular dissociation or
ventriculoatrial block. On intracardiac electrograms, all previously
published criteria for BBR were fulfilled, and in addition, whenever there
was a change in the cycle length of tachycardia, the His to His cycle
length variation produced similar changes in ventricular activation during
subsequent complexes with no relation to the preceding ventricular
activation cycles. Compared with patients with ventricular tachycardia due
to mechanisms unrelated to BBR, patients with BBR had frequent combination
of nonspecific intraventricular conduction defects and prolonged HV
intervals (100% vs. 11%, p less than 0.001). When this combination was
associated with a tachycardia showing a left bundle branch block pattern,
BBR accounted for the majority compared with mechanisms unrelated to BBR
(73% vs. 27%, p less than 0.01). The above finding in patients with dilated
cardiomyopathy should raise the suspicion of sustained BBR because dilated
cardiomyopathy was observed in 95% of the patients with BBR. Twelve of the
20 patients were treated with antiarrhythmic agents, and the other eight
were managed by selective catheter ablation of the right bundle branch with
electrical energy. Our data suggest that sustained BBR is not an uncommon
mechanism of tachycardia; it can be induced readily in the laboratory and
is amendable to catheter ablation by the very nature of its circuit. The
clinical and electrophysiologic features outlined in this study should
enable one to correctly diagnose this important arrhythmia.
ARTICLES
Sustained bundle branch reentry as a mechanism of clinical tachycardia
Electrophysiology Laboratory University of Wisconsin, Sinai Samaritan Medical Center, Milwaukee 53201.
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