Purkinje‐related Arrhythmias Part II: Polymorphic Ventricular Tachycardia and Ventricular Fibrillation

There has been growing evidence that the Purkinje network plays a pivotal role in both the initiation and perpetuation of ventricular fibrillation (VF). A triggering ventricular premature beat (VPB) with a short‐coupling interval could arise from either the right or left Purkinje system in patients with polymorphic ventricular tachycardia (VT) or VF, and that can be suppressed by the catheter ablation of the trigger. A focal breakdown in the “gating mechanism” at the Purkinje system resulting in a short‐circuiting of the transmission across the gate at the distal Purkinje network might predispose to reentrant circuits of polymorphic VT/VF. Many investigators also reported the successful ablation of Purkinje‐related VF with an acute or remote myocardial infarction. The same approach with good short‐term results has been reported in a small number of patients with other heart diseases (i.e., amyloidosis, chronic myocarditis, nonischemic cardiomyopathy). Catheter ablation of the triggering VPBs from the Purkinje system can be used as an electrical bailout therapy in patients with VF storm. (PACE 2011; 34:1034–1049)

[1]  A. Nogami,et al.  Electrophysiologic and histopathologic findings of the ablation sites for ventricular fibrillation in a patient with ischemic cardiomyopathy , 2009, Journal of Interventional Cardiac Electrophysiology.

[2]  Prashanthan Sanders,et al.  Mapping and ablation of polymorphic ventricular tachycardia after myocardial infarction. , 2004, Journal of the American College of Cardiology.

[3]  K. Aonuma,et al.  Successful catheter ablation of bidirectional ventricular premature contractions triggering ventricular fibrillation in catecholaminergic polymorphic ventricular tachycardia with RyR2 mutation. , 2012, Circulation. Arrhythmia and electrophysiology.

[4]  S. Narayan,et al.  Long-term follow-up of idiopathic ventricular fibrillation ablation: a multicenter study. , 2009, Journal of the American College of Cardiology.

[5]  David O. Martin,et al.  Mode of initiation and ablation of ventricular fibrillation storms in patients with ischemic cardiomyopathy. , 2004, Journal of the American College of Cardiology.

[6]  J Jalife,et al.  Purkinje-muscle reentry as a mechanism of polymorphic ventricular arrhythmias in a 3-dimensional model of the ventricles. , 1998, Circulation research.

[7]  P. Coumel,et al.  Catecholaminergic polymorphic ventricular tachycardia in children. A 7-year follow-up of 21 patients. , 1995, Circulation.

[8]  G. Hindricks,et al.  Ablation of Polymorphic Ventricular Tachycardias in Patients with Structural Heart Disease , 2008, Pacing and clinical electrophysiology : PACE.

[9]  H. Pak,et al.  Catheter ablation of ventricular fibrillation in rabbit ventricles treated with beta-blockers. , 2003, Circulation.

[10]  J. Brachmann,et al.  Role of Left Ventricular Scar and Purkinje‐Like Potentials During Mapping and Ablation of Ventricular Fibrillation in Dilated Cardiomyopathy , 2009, Pacing and clinical electrophysiology : PACE.

[11]  S. Priori,et al.  Purkinje cell calcium dysregulation is the cellular mechanism that underlies catecholaminergic polymorphic ventricular tachycardia. , 2010, Heart rhythm.

[12]  P. Tchou,et al.  Ventricular Fibrillation: Ablation of a Trigger? , 2002, Journal of cardiovascular electrophysiology.

[13]  B F Hoffman,et al.  Electrophysiological Properties of the Canine Peripheral A‐V Conducting System , 1970 .

[14]  Prashanthan Sanders,et al.  Mapping and Ablation of Ventricular Fibrillation Associated With Long-QT and Brugada Syndromes , 2003, Circulation.

[15]  Michel Haïssaguerre,et al.  Mapping and Ablation of Idiopathic Ventricular Fibrillation , 2002, Frontiers in cardiovascular medicine.

[16]  J Jalife,et al.  Ventricular fibrillation: mechanisms of initiation and maintenance. , 2000, Annual review of physiology.

[17]  T. Tsuchiya,et al.  Transition from Purkinje Fiber‐Related Rapid Polymorphic Ventricular Tachycardia to Sustained Monomorphic Ventricular Tachycardia in a Patient with a Structurally Normal Heart: A Case Report , 2007, Journal of cardiovascular electrophysiology.

[18]  P. Coumel,et al.  Short-coupled variant of torsade de pointes. A new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias. , 1994, Circulation.

[19]  Raymond E. Ideker,et al.  Activation Patterns of Purkinje Fibers During Long-Duration Ventricular Fibrillation in an Isolated Canine Heart Model , 2007, Circulation.

[20]  R. Holland,et al.  The QRS complex during myocardial ischemia. An experimental analysis in the porcine heart. , 1976, The Journal of clinical investigation.

[21]  Michel Haïssaguerre,et al.  Role of Purkinje conducting system in triggering of idiopathic ventricular fibrillation , 2002, The Lancet.

[22]  José Jalife,et al.  Arrhythmogenic Mechanisms in a Mouse Model of Catecholaminergic Polymorphic Ventricular Tachycardia , 2007, Circulation research.

[23]  Jonathan C. Newton,et al.  The Transmural Activation Sequence in Porcine and Canine Left Ventricle Is Markedly Different During Long‐Duration Ventricular Fibrillation , 2007, Journal of cardiovascular electrophysiology.

[24]  W. Cascio,et al.  Electrical Properties and Conduction in Reperfused Papillary Muscle , 2001, Circulation research.

[25]  J. Toyama,et al.  Mapping and Ablation of Trigger Premature Ventricular Contractions in a Case of Electrical Storm Associated with Ischemic Cardiomyopathy , 2007, Pacing and clinical electrophysiology : PACE.

[26]  J Jalife,et al.  Supernormal excitability as a mechanism of chaotic dynamics of activation in cardiac Purkinje fibers. , 1990, Circulation research.

[27]  W. Saliba,et al.  Catheter Ablation of Ventricular Fibrillation Storm in Patients with Infiltrative Amyloidosis of the Heart , 2006, Cardiovascular Electrophysiology.

[28]  Hui-Nam Pak,et al.  Catheter Ablation of Ventricular Fibrillation in Rabbit Ventricles Treated With &bgr;-Blockers , 2003 .

[29]  R. Ideker,et al.  Transmural and endocardial Purkinje activation in pigs before local myocardial activation after defibrillation shocks. , 2007, Heart rhythm.

[30]  Jian Huang,et al.  Chemical ablation of the Purkinje system causes early termination and activation rate slowing of long-duration ventricular fibrillation in dogs. , 2008, American journal of physiology. Heart and circulatory physiology.

[31]  Hui-Nam Pak,et al.  Role of the Posterior Papillary Muscle and Purkinje Potentials in the Mechanism of Ventricular Fibrillation in Open Chest Dogs and Swine: Effects of Catheter Ablation , 2006, Journal of cardiovascular electrophysiology.

[32]  A. L. Wit,et al.  Survival of Subendocardial Purkinje Fibers after Extensive Myocardial Infarction in Dogs: IN VITRO AND IN VIVO CORRELATIONS , 1973, Circulation research.

[33]  Ali Massumi,et al.  Idiopathic Ventricular Fibrillation Successfully Terminated by Radiofrequency Ablation of the Distal Purkinje Fibers , 2007, Pacing and clinical electrophysiology : PACE.

[34]  R. Myerburg,et al.  Physiology of Canine Intraventricular Conduction and Endocardial Excitation , 1972, Circulation research.

[35]  Shigeru Nakamura,et al.  Catheter ablation of fatal ventricular tachyarrhythmias storm in acute coronary syndrome—role of Purkinje fiber network , 2009, Journal of interventional cardiac electrophysiology.

[36]  A. Russo,et al.  Ventricular Tachycardia/Ventricular Fibrillation Ablation in the Setting of Ischemic Heart Disease , 2005, Journal of cardiovascular electrophysiology.

[37]  J. Kupersmith,et al.  Marked action potential prolongation as a source of injury current leading to border zone arrhythmogenesis. , 1994, American heart journal.

[38]  A Garfinkel,et al.  Role of papillary muscle in the generation and maintenance of reentry during ventricular tachycardia and fibrillation in isolated swine right ventricle. , 1999, Circulation.

[39]  M. Scheinman,et al.  Role of the His-Purkinje system in the genesis of cardiac arrhythmia. , 2009, Heart rhythm.

[40]  H. Pak,et al.  Both Purkinje cells and left ventricular posteroseptal reentry contribute to the maintenance of ventricular fibrillation in open-chest dogs and swine: effects of catheter ablation and the ventricular cut-and-sew operation. , 2008, Circulation journal : official journal of the Japanese Circulation Society.

[41]  S. Ernst,et al.  Successful Catheter Ablation of Electrical Storm After Myocardial Infarction , 2003, Circulation.

[42]  R Lazzara,et al.  Functional anatomy of the canine left bundle branch. , 1974, The American journal of cardiology.

[43]  A. Nogami,et al.  Mapping and ablation of idiopathic ventricular fibrillation from the Purkinje system. , 2005, Heart rhythm.

[44]  田淵 淳,et al.  Das Reizleitungssystem des Säugetierherzens : eine anatomisch-histologische Studie über das Atrioventrikularbündel und die Purkinjeschen Fäden , 1906 .

[45]  M J Janse,et al.  Electrophysiological changes and ventricular arrhythmias in the early phase of regional myocardial ischemia. , 1981, Circulation research.

[46]  Ruben Coronel,et al.  Activation Delay After Premature Stimulation in Chronically Diseased Human Myocardium Relates to the Architecture of Interstitial Fibrosis , 2001, Circulation.

[47]  R. A. Gray,et al.  Mechanisms of Cardiac Fibrillation , 1995, Science.

[48]  R. Myerburg,et al.  The Gating Mechanism in the Distal Atrioventricular Conducting System , 1971, Circulation.