Commentary
Complex reentrant VT involving the ventricular septal substrate in the
para-Hisian region has been reported.1 Ablation
procedures in this anatomical region pose challenges due to the
potential risk of damaging the AV conduction system. Accurately
determining the optimal ablation site is crucial, necessitating a clear
understanding of the arrhythmia mechanism. In the present case, WCT was
diagnosed as para-Hisian VT based on AV dissociation, the absence of
visual His bundle potentials, and a focal breakout pattern from the
para-Hisian region on the electroanatomical activation map.
As shown in Figure 1, overdrive pacing from the RVA during VT reveals
the fully pacing morphology, whereas overdrive pacing from the atrial
septum exhibits constant fusion, indicating manifest entrainment. These
observations led to the determination of a reentry mechanism for VT.
Furthermore, the electroanatomical activation map indicated a focal
breakout pattern with prolonged and fractionated potentials originating
from the para-Hisian region, suggesting a localized reentry involving a
slow conduction zone (SCZ) within the interventricular septum with
endocardial breakout. Fractionated potentials preceding QRS onset by 56
ms were recorded when a 3.5mm tip ablation catheter was positioned
within the NCC, corresponding to the opposite side of the para-Hisian
region. Figure 2B illustrates concealed entrainment observed during the
first to fourth pacing stimuli of ventricular entrainment pacing at this
NCC site. In the fifth pacing stimulus, VT was terminated without
ventricular electrocardiograms or QRS waveforms, and VT was reinduced
after the last pacing stimulus. This phenomenon, termed VT termination
with nonglobal capture by a pacing stimulus, aids in identifying a
critical isthmus within the reentry circuit.2 In the
present case, the absence of His bundle potential was confirmed at this
site during sinus rhythm, and radiofrequency ablation successfully
eliminated the inducible VT without impairing AV conduction.
Figures 3A and B present intracardiac electrograms during sinus rhythm
and atrial entrainment pacing, respectively. Ventricular potentials on
His-d electrodes were captured antidromically, and RVA potentials were
captured orthodromically, demonstrating manifest entrainment. On the His
3,4 electrode, the fractionated ventricular potential preceding QRS
onset by 56 ms was documented during VT, and only the negative potential
of the initial half component, circled in red, was captured
orthodromically with 0 ms preceding QRS onset during atrial entrainment
pacing. These observations suggested that the negative potential of the
initial half-component corresponded to the exit site of the SCZ of VT
reentry circuit.
We explored the mechanism by which the overdrive pacing from the atrium,
rather than from the RVA, demonstrated manifest entrainment. We
speculated that the re-entrant circuit was within the interventricular
septum, where the exit and entrance sites of the SCZ were located on the
right ventricular (RV) and left ventricular (LV) sides, respectively
(Figure 3C). The entrainment response from the RVA demonstrated an
absence of constant fusion, as the N-th paced antidromic wavefront
reached the exit of the SCZ earlier than the N-1st paced orthodromic
wavefront. In contrast, the entrainment response from the atrium
demonstrated constant fusion. This phenomenon is caused by the N-1st
paced wavefront conducting through the left bundle due to the CRBBB. The
wavefront then reached the entrance of the SCZ via the Purkinje network
on the ventricular septal surface formed by the fascicles of the left
bundle branch. Subsequently, it collided with the N-th antidromic
wavefront after propagating from the exit of the SCZ toward the RVA
(Figure 3C).
The present case highlights the effectiveness of the entrainment pacing
from both the atrium and the NCC in identifying the optimal ablation
site. This approach could minimize the risk of injuring the AV node
while confirming the VT mechanism as reentry.