Idiopathic LV VT and Bundle Branch Reentrant VT

Raja Selvaraj
Cardiac Electrophysiologist
Professor of Cardiology
JIPMER

Bundle branch reentry

Presentation

• Wide QRS tachycardia with typical BBB pattern
• Evidence of infra-His disease
• Specific pathologies
  • Aortic valve disease
  • Non ischemic cardiomyopathy

Sinus ECG

Tachy ECG

Positive HV

Wobble

BBRT - Case 1

Sinus ECG

Intracardiac

RV 400/500/280

RV 400/500/260

Tachy ECG

RV entrainment

Right bundle

Ablation

Post ablation

BBRT - Case 2

Case

• Middle aged male
• ICD for post MI LV dysfunction
• Recurrent appropriate therapies

ECG - Incomplete LBBB

Basal measurements

HV prolongation with A extra

V extra

V extra with Tachy induction

PPI from RV apex

LB recording

Induction with LB recording

Induction with LB recording

After LB ablation

Idiopathic LV fascicular VT

Typical presentation

• Young
• Palpitations with exertion
• Relatively narrow WQRST
• RBBB / LAD
• Sensitive to Verapamil

Presentation

• Usually paroxysmal
• Can be incessant with LV dysfunction

ECG

Circuit

Circuit - P1 and P2 potentials

Induction with atrial pacing

Diagnosis

• VA - 1:1 or V>A
• Negative HV

V > A

Mapping

• Earliest activation (V or P2 potential)
• Locations with P1 potential
• Septal contact essential
• Multipolar catheters ?

Ablation

Bystander activation of adjacent conduction system

When tachycardia is not inducible

• Linear transection of left posterior fascicle
• Pace mapping
• "Retro-" potentials

Retro potentials