Entrainment response during ventricular tachycardia originating from the
para-Hisian region: What is the mechanism?
Abstract
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?