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, supraventricular tachycardia [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 [LBBB]), and most have a prolonged His to ventricle (HV) interval. It is important to consider that although we speak of LBBB as an electrocardiographic pattern, the phenomena is typically a delay rather than a block, as retrograde complete LBBB 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.
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