Circulation, Vol 88, 2607-2617, Copyright © 1993 by American Heart Association
H Nakagawa, KJ Beckman, JH McClelland, X Wang, M Arruda, I Santoro, HA Hazlitt, I Abdalla, A Singh and H Gossinger
BACKGROUND. Verapamil-sensitive, idiopathic left ventricular tachycardia
(ILVT) with right bundle branch block configuration and left-axis deviation
has been suggested to originate from the left posterior fascicle. The
purpose of this study was to determine how frequently potentials generated
by the Purkinje fiber network (P potential) can be recorded preceding
ventricular activation, and the role of the P potential in guiding
radiofrequency catheter ablation. METHODS AND RESULTS. Eight patients (mean
age, 26 +/- 10 years) with ILVT (cycle length, 346 +/- 59 milliseconds)
were studied. Right and left ventricular endocardial mapping during
tachycardia identified earliest ventricular activation at the posteroapical
left ventricular septum. In all patients, earliest ventricular activation
during tachycardia was preceded by a distinct potential. This potential
also preceded ventricular activation during sinus rhythm, consistent with
activation of a segment of the left posterior fascicle (P potential). The
earliest recorded P potential preceded the QRS during tachycardia by 15 to
42 milliseconds (mean, 27 +/- 9 milliseconds). The application of
radiofrequency current at 1 to 4 sites (median, 1) eliminated ILVT in all
eight patients. In the seven patients with P potentials recorded at
multiple sites within the posteroapical septum, ablation was successful at
the site of the earliest P potential and unrelated to the timing of
ventricular activation. In the remaining patient, ablation was successful
at a site recording a late P potential fusing with earliest ventricular
activation. During follow-up (1 to 67 months; median, 10.5) ILVT recurred
only in the latter patient. Pace mapping during tachycardia at the
successful ablation site in four patients produced a similar QRS with
stimulus-QRS interval equal to P-QRS interval during tachycardia. However,
a similar QRS was obtained by pacing at nearby sites that recorded a later
P potential. CONCLUSIONS. These findings support the hypothesis that ILVT
originates from the Purkinje network of the left posterior fascicle. A P
potential can be recorded at the posteroapical left ventricular septum
during ILVT, and ablation is successful at the site recording the earliest
P potential. Pace mapping with similar QRS is not specific due to capture
of the Purkinje fiber network at a site remote from the origin of the
tachycardia.
ARTICLES
Radiofrequency catheter ablation of idiopathic left ventricular tachycardia guided by a Purkinje potential
Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City 73190-3048.
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