Case presentation
A 70-year-old man presented with regular wide QRS complex tachycardia
(WCT) at a rate of 185 beats/min, characterized by left bundle branch
block morphology. WCT termination was achieved through electrical
cardioversion. A subsequent 12-lead electrocardiogram revealed sinus
rhythm with complete right bundle branch block (CRBBB) morphology.
Echocardiography showed normal left ventricular function without
structural heart disease. An electrophysiological study was then
conducted, followed by catheter ablation. At baseline, the atrio-His and
His-ventricular intervals were normal. Fractionated ventricular
potentials were observed in the para-Hisian region during sinus rhythm.
Neither dual atrioventricular (AV) nodal physiology nor ventriculoatrial
conduction was observed during programmed pacing. Clinical WCT was
induced by ventricular extra-stimulation with concurrent AV dissociation
and no visual His bundle potential, confirming the diagnosis of
ventricular tachycardia (VT).
Figure 1 illustrates 12-lead electrocardiograms recorded during
overdrive pacing from the right ventricular apex (RVA) and right atrial
septum during VT. The electroanatomical activation map revealed a
distinctive focal breakout pattern with fractionated potentials
originating from the para-Hisian region. In the noncoronary cusp (NCC),
corresponding to the opposite side of the para-Hisian region, prolonged
and fractionated ventricular potentials preceding QRS onset by 56 ms
were recorded (Figure 2A). Figure 2B shows the intracardiac electrogram
recorded during ventricular overdrive pacing from the NCC during VT.
Based on these observations, what is the mechanisms underlying the
tachycardia?