Phanthawimol Wipat, Nogami Akihiko, Haruna Tetsuya, Morishima Itsuro, Hasebe Hideyuki, Mizutani Yoshiaki, Naeemah Qasim J, Shimoo Satoshi, Hattori Masayuki, Ichihara Noboru, Komatsu Yuki, Kuroki Kenji, Yamasaki Hiro, Igarashi Miyako, Aonuma Kazutaka, Ieda Masaki
Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
JACC Clin Electrophysiol. 2021 Jul;7(7):843-854. doi: 10.1016/j.jacep.2020.11.022. Epub 2021 Feb 24.
This study sought to demonstrate a new type of verapamil-sensitive fascicular ventricular tachycardia (VT) with a reverse circuit.
Left posterior fascicular ventricular tachycardia (LPFVT) is the most common form of verapamil-sensitive fascicular VT. Reverse-type LPFVT has not been reported.
We searched for a reverse-type LPFVT among 242 patients with verapamil-sensitive VT from February 2006 to September 2019.
Three patients had a reverse-type LPFVT (cycle lengths: 340, 360, and 340 ms). QRS configuration during VT was narrow (140, 150, and 140 ms) and exhibited rSr' morphology in V with an early precordial transition and inferior axis. Two of 3 patients had common-type LPFVT. During reverse-type LPFVT, the earliest ventricular activation was the left superior middle septum. Fragmented Purkinje potentials (P1) buried within the local ventricular electrogram were recorded with an activation sequence from the apex to the base and were linked to the subsequent left ventricular septal activation. After radiofrequency catheter ablation at P1 during LPFVT, the reverse-type LPFVT also became noninducible. In 1 patient with only the reverse-type LPFVT, radiofrequency catheter ablation at the earliest LV activation site suppressed VT. These findings suggest that this new type of verapamil-sensitive fascicular VT shares a re-entrant circuit with a reverse direction of common LPFVT with an intramural exit site at the superior middle septum.
Reverse-type LPFVT can occur. If common LPFVT exists, diastolic P1 during LPFVT can be a common target of ablation. If only reverse-LPFVT is inducible, the earliest ventricular activation site can be a target.
本研究旨在证实一种具有逆向折返环的新型对维拉帕米敏感的分支型室性心动过速（VT）。
左后分支型室性心动过速（LPFVT）是对维拉帕米敏感的分支型VT最常见的形式。逆向型LPFVT尚未见报道。
我们在2006年2月至2019年9月期间对242例对维拉帕米敏感的VT患者进行了逆向型LPFVT的筛查。
3例患者存在逆向型LPFVT（周长：340、360和340毫秒）。VT发作时QRS波形态窄（140、150和140毫秒），V导联呈rSr′形态，胸前导联过渡早且电轴下偏。3例患者中有2例存在普通型LPFVT。在逆向型LPFVT发作时，最早的心室激动部位是左上中间隔。在局部心室电图中记录到埋于其中的碎裂浦肯野电位（P1），其激动顺序从心尖向心底，且与随后的左心室间隔激动相关。在LPFVT发作时对P1进行射频导管消融后，逆向型LPFVT也不能被诱发。在1例仅存在逆向型LPFVT的患者中，在最早的左心室激动部位进行射频导管消融可抑制VT。这些发现提示，这种新型对维拉帕米敏感的分支型VT与普通LPFVT具有逆向折返环，其壁内出口部位位于上中间隔。
逆向型LPFVT可以发生。如果存在普通型LPFVT，LPFVT发作时的舒张期P1可作为共同的消融靶点。如果仅能诱发逆向型LPFVT，最早的心室激动部位可作为靶点。
