Bundle branch reentrant ventricular tachycardia
- David J Callans, MD
David J Callans, MD
- Professor of Medicine
- University of Pennsylvania School of Medicine
Bundle branch reentrant ventricular tachycardia (BBRVT) is a unique arrhythmia because the tachycardia circuit is dependent exclusively on the specialized conduction system [1-3]. This has two important implications: a large portion of the circuit can be recorded directly, and the circuit is uniquely sensitive to the effects of focal ablation. The circuit involves antegrade conduction over the right bundle branch and retrograde conduction over the left bundle branch; the His bundle is adjacent to but separate from the circuit.
BBRVT can be very rapid (often >200 bpm), often resulting in syncope or cardiac arrest. It is a relatively rare arrhythmia, usually seen in patients with advanced structural heart disease, and it forms part of the differential diagnosis of wide complex tachycardias (in addition to myocardial VT, SVT with aberrancy of the left bundle branch, pre-excited tachycardias using nodofascicular or atrial fascicular bypass tracts) . (See "Approach to the diagnosis of wide QRS complex tachycardias".)
A related disorder, intrafascicular reentry, utilizes the separate fascicles of the left bundle branch. It, too, is typically observed in patients with advanced structural heart disease [5,6]. Both arrhythmias depend on conduction delay in the His Purkinje system.
The mechanisms, clinical features, and treatment of BBRVT will be discussed here. The general approach to wide QRS complex tachycardias as well as the treatment of VT of other etiologies (ie, ischemic, scar-related) are discussed separately. (See "Approach to the diagnosis of wide QRS complex tachycardias" and "Sustained monomorphic ventricular tachycardia in patients with a prior myocardial infarction: Treatment and prognosis".)
MECHANISM AND THE RESULTANT ELECTROCARDIOGRAM
In sinus rhythm, most patients with BBRVT have a prolonged QRS (nonspecific conduction delay or left bundle branch block), and most have a prolonged His to ventricle (HV) interval. It is important to consider that although we speak of left bundle branch block as an electrocardiographic pattern, the phenomena is typically a delay rather than a block, as retrograde complete left bundle branch block would make this arrhythmia circuit impossible. The arrhythmia begins when one or more premature ventricular beats arise and conduct into both the right bundle branch, where retrograde activation is blocked due to refractoriness from the preceding normally conducted antegrade beat, and into the left bundle branch, which has a shorter refractory period than the right bundle branch (figure 1). As a result, the impulse conducts retrogradely up the left bundle branch to the bundle of His, although the His bundle is not an essential component of the circuit. The impulse then conducts antegradely down the right bundle branch, activating the ventricle at the termination of the right bundle branch. For this reason, the QRS during VT has an LBBB pattern and may closely resemble the sinus rhythm QRS if baseline LBBB is present. If the timing is right and slow conduction through the circuit allows for recovery from refractoriness of all of the component parts, sustained reentry may be established.
- Lloyd EA, Zipes DP, Heger JJ, Prystowsky EN. Sustained ventricular tachycardia due to bundle branch reentry. Am Heart J 1982; 104:1095.
- Caceres J, Jazayeri M, McKinnie J, et al. Sustained bundle branch reentry as a mechanism of clinical tachycardia. Circulation 1989; 79:256.
- Nogami A. Purkinje-related arrhythmias part I: monomorphic ventricular tachycardias. Pacing Clin Electrophysiol 2011; 34:624.
- Delacretaz E, Stevenson WG, Ellison KE, et al. Mapping and radiofrequency catheter ablation of the three types of sustained monomorphic ventricular tachycardia in nonischemic heart disease. J Cardiovasc Electrophysiol 2000; 11:11.
- Crijns HJ, Smeets JL, Rodriguez LM, et al. Cure of interfascicular reentrant ventricular tachycardia by ablation of the anterior fascicle of the left bundle branch. J Cardiovasc Electrophysiol 1995; 6:486.
- Lopera G, Stevenson WG, Soejima K, et al. Identification and ablation of three types of ventricular tachycardia involving the his-purkinje system in patients with heart disease. J Cardiovasc Electrophysiol 2004; 15:52.
- Cohen TJ, Chien WW, Lurie KG, et al. Radiofrequency catheter ablation for treatment of bundle branch reentrant ventricular tachycardia: results and long-term follow-up. J Am Coll Cardiol 1991; 18:1767.
- Blanck Z, Dhala A, Deshpande S, et al. Bundle branch reentrant ventricular tachycardia: cumulative experience in 48 patients. J Cardiovasc Electrophysiol 1993; 4:253.
- Merino JL, Peinado R, Fernández-Lozano I, et al. Transient entrainment of bundle-branch reentry by atrial and ventricular stimulation: elucidation of the tachycardia mechanism through analysis of the surface ECG. Circulation 1999; 100:1784.
- Merino JL, Peinado R, Fernandez-Lozano I, et al. Bundle-branch reentry and the postpacing interval after entrainment by right ventricular apex stimulation: a new approach to elucidate the mechanism of wide-QRS-complex tachycardia with atrioventricular dissociation. Circulation 2001; 103:1102.
- Li YG, Grönefeld G, Israel C, et al. Bundle branch reentrant tachycardia in patients with apparent normal His-Purkinje conduction: the role of functional conduction impairment. J Cardiovasc Electrophysiol 2002; 13:1233.
- Tchou P, Jazayeri M, Denker S, et al. Transcatheter electrical ablation of right bundle branch. A method of treating macroreentrant ventricular tachycardia attributed to bundle branch reentry. Circulation 1988; 78:246.
- Volkmann H, Kühnert H, Dannberg G, Heinke M. Bundle branch reentrant tachycardia treated by transvenous catheter ablation of the right bundle branch. Pacing Clin Electrophysiol 1989; 12:258.
- Tai YT, Lee KL. Pleomorphic ventricular tachycardia with antegrade His-bundle activation: elucidation by multiple His-bundle recordings. J Cardiovasc Electrophysiol 1994; 5:350.
- European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247.
- Blanck Z, Deshpande S, Jazayeri MR, Akhtar M. Catheter ablation of the left bundle branch for the treatment of sustained bundle branch reentrant ventricular tachycardia. J Cardiovasc Electrophysiol 1995; 6:40.
- Blanck Z, Akhtar M. Ventricular tachycardia due to sustained bundle branch reentry: diagnostic and therapeutic considerations. Clin Cardiol 1993; 16:619.
- Mehdirad AA, Keim S, Rist K, Tchou P. Long-term clinical outcome of right bundle branch radiofrequency catheter ablation for treatment of bundle branch reentrant ventricular tachycardia. Pacing Clin Electrophysiol 1995; 18:2135.
- Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350.