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Mapping and ablation of polymorphic ventricular tachycardia after myocardial infarction

Lukasz Szumowski, MD, PhD^*,*, Prashanthan Sanders, MBBS, PhD, Franciszek Walczak, MD, PhD^*, Mélèze Hocini, MD, Pierre Jaïs, MD, Roman Kepski, PhD^*, Ewa Szufladowicz, MD, PhD^*, Piotr Urbanek, MD^*, Pawe Derejko, MD^*, Robert Bodalski, MD^* and Michel Haïssaguerre, MD

^* Institute of Cardiology, Warsaw, Poland
Hopital Cardiologique du Haut-Leveque and the Université Victor Segalen Bordeaux II, Bordeaux, France

View larger version (21K): [in a new window]   Figure 1 Examples of frequent isolated premature beats followed by the initiation of polymorphic ventricular tachycardia.

View larger version (51K): [in a new window]   Figure 2 Electroanatomic bipolar voltage map of Patient #4 performed during sinus rhythm. The voltage map delineates the region of scar border-zone. Note that the premature beats originating from the Purkinje network are in this border-zone, where successful ablation was performed (brown tags). Purple tags represent sites recording Purkinje potentials in sinus rhythm, and white tags represent fractionated complex electrograms.

View larger version (25K): [in a new window]   Figure 3 Electroanatomic bipolar voltage and activation map in Patient #3 performed during premature beats. The activation map demonstrates the centrifugal activation from the border-zone of the scar. The voltage map (right panel) delineates the region of scar border-zone. Note that the premature beats originating from the Purkinje network are in this border-zone, where successful ablation was performed (brown tags). Purple tags represents sites recording Purkinje potentials, and white tags represent fractionated complex electrograms.

View larger version (21K): [in a new window]   Figure 4 Mapping at the site of earliest activity during premature beats. Note that the Purkinje potential (*) precedes the ventricular activation during both sinus rhythm and the premature beat. Also, the width of the premature beat is quite similar to that during sinus rhythm.

View larger version (35K): [in a new window]   Figure 5 Purkinje potential (*) preceding each beat of tachycardia, suggestive of driving the tachycardia. The morphology of the ventricular complexes, originating from the Purkinje fibers, is changing, suggesting different Purkinje-muscle outbreak.

View larger version (19K): [in a new window]   Figure 6 Purkinje potential preceding both sinus and premature beats (*). The last beat demonstrates Purkinje to muscle conduction block.