Komatsu Yuki, Nogami Akihiko, Kurosaki Kenji, Morishima Itsuro, Masuda Keita, Ozawa Tomoya, Kaneshiro Takashi, Hanaki Yuichi, Shinoda Yasutoshi, Talib Ahmed Karim, Kowase Shinya, Sekiguchi Yukio, Aonuma Kazutaka
From the Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Japan (Y.K., A.N., K.M., A.K.T., K.A., Y. Shinoda, Y. Sekiguchi); Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.K., Y.H., S.K.); Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Japan (T.O.); and Department of Cardiology and Hematology, Fukushima Medical University, Japan (T.K.).
Circ Arrhythm Electrophysiol. 2017 Mar;10(3). doi: 10.1161/CIRCEP.116.004549.
Verapamil-sensitive fascicular ventricular tachycardia (FVT) has been demonstrated to be a reentrant mechanism using the Purkinje network as a part of its reentrant circuit. Although the papillary muscles (PMs) are implicated in arrhythmogenic structure, reentrant FVT originating from the PMs has not been well defined.
We studied 13 patients in whom FVT was successfully eliminated by ablation at the posterior PMs (n=8; PPM-FVT) and anterior PMs (n=5; APM-FVT). Although intravenous administration of verapamil (5 mg) terminated ventricular tachycardia (VT) in 6 patients, VT was only slowed in the remaining 7 patients. PPM-FVT exhibited right bundle branch block and superior right axis (extreme right axis) or horizontal axis deviation. APM-FVT exhibited right bundle branch block configuration and right axis deviation with deep S wave in leads I, V, and V. VT was reproducibly induced by programmed atrial or ventricular stimulation. His-ventricular interval during VT was shorter than that during sinus rhythm. Ablation at the left posterior or anterior fascicular regions often changed the QRS morphology but did not completely eliminate it. Mid-diastolic Purkinje potentials were recorded during VT around the PMs, where ablation successfully eliminated the tachycardia. All patients have been free from recurrent VT after ablation.
Reentrant circuit of verapamil-sensitive FVT can involve the Purkinje network lying around the PMs. PM-FVT is a distinct entity that is characterized by distinctive electrocardiographic characteristics and less sensitivity to verapamil administration compared with common type FVT. Ablation targeting the mid-diastolic Purkinje potentials around the PMs during tachycardia can be effective in suppressing this arrhythmia.
对维拉帕米敏感的分支性室性心动过速（FVT）已被证实是一种折返机制，其折返环的一部分利用浦肯野网络。虽然乳头肌（PMs）与致心律失常结构有关，但起源于PMs的折返性FVT尚未得到很好的定义。
我们研究了13例FVT通过在后侧PMs（n = 8；PPM - FVT）和前侧PMs（n = 5；APM - FVT）消融成功消除的患者。虽然静脉注射维拉帕米（5 mg）使6例患者的室性心动过速（VT）终止，但其余7例患者的VT仅被减慢。PPM - FVT表现为右束支传导阻滞和右上轴（极右轴）或水平轴偏移。APM - FVT表现为右束支传导阻滞形态和右轴偏移，在I、V和V导联有深S波。通过程控心房或心室刺激可重复性诱发VT。VT期间的希氏束 - 心室间期短于窦性心律期间。在左后或前分支区域消融常改变QRS形态，但不能完全消除。在VT期间，在PMs周围记录到舒张中期浦肯野电位，在此处消融成功消除了心动过速。所有患者在消融后均未再发VT。
对维拉帕米敏感的FVT的折返环可涉及PMs周围的浦肯野网络。PM - FVT是一种独特的实体，其特征是具有独特的心电图特征，与常见类型的FVT相比，对维拉帕米给药的敏感性较低。在心动过速期间，针对PMs周围舒张中期浦肯野电位进行消融可有效抑制这种心律失常。
