Abstract
BackgroundThe short-coupled variant of torsade de pointes (sc-TdP) is a malignant arrhythmia that frequently presents with ventricular fibrillation (VF) electrical storm. Verapamil is considered the first-line therapy of sc-TdP while catheter ablation is not widely adopted. The aim of this study was to determine the origin of sc-TdP and to assess the outcome of catheter ablation using 3D-mapping.Methods and resultsWe retrospectively analyzed five patients with sc-TdP who underwent 3D-mapping and ablation of sc-TdP at five different institutions. Four patients initially presented with sudden cardiac arrest, one patient experienced recurrent syncope as the first manifestation. All patients demonstrated a monomorphic premature ventricular contraction (PVC) with late transition left bundle branch block pattern, superior axis, and a coupling interval of less than 300 ms. triggering recurrent TdP and VF. In four patients, the culprit PVC was mapped to the free wall insertion of the moderator band (MB) with a preceding Purkinje potential in two patients. Catheter ablation using 3D-mapping and intracardiac echocardiography eliminated sc-TdP in all patients, with no recurrence at mean 2.7 years (range 6 months to 8 years) of follow-up.Conclusion3D-mapping and intracardiac echocardiography demonstrate that sc-TdP predominantly originates from the MB free wall insertion and its Purkinje network. Catheter ablation of the culprit PVC at the MB free wall junction leads to excellent short- and long-term results and should be considered as first-line therapy in recurrent sc-TdP or electrical storm.Graphic abstract
Highlights
The short-coupled variant of torsade de pointes was originally described by Leenhardt et al in 1994 who reported 14 patients with structurally normal hearts, absence of QT interval prolongation, and TdP induced by a premature ventricular contraction (PVC) with late transition left bundle branch block (LBBB) pattern, left superior axis, and a coupling interval of less than 300 ms consistent with a right ventricular (RV) moderator band (MB) origin [1,2,3]
Based on the introduction of imaging techniques such as 3D-mapping [4] and intracardiac echocardiography (ICE) [5], short-coupled variant of torsade de pointes (sc-TdP) and idiopathic ventricular fibrillation from the MB have been characterized as different clinical entities which still translates into different therapeutic approaches [1,2,3]: Verapamil is still considered the first-line therapy in sc-TdP [6] whereas catheter ablation is the treatment of choice for iVF from the MB [2, 3]
We have demonstrated that sc-TdP predominantly originates from the free wall insertion of the RV MB and its Purkinje network and high-resolution 3D-mapping and ICE may be useful to precisely locate the triggering PVC in this region facilitating successful catheter ablation
Summary
The short-coupled variant of torsade de pointes (sc-TdP) was originally described by Leenhardt et al in 1994 who reported 14 patients with structurally normal hearts, absence of QT interval prolongation, and TdP induced by a premature ventricular contraction (PVC) with late transition left bundle branch block (LBBB) pattern, left superior axis, and a coupling interval of less than 300 ms consistent with a right ventricular (RV) moderator band (MB) origin [1,2,3]. Catheter ablation using 3D-mapping and intracardiac echocardiography eliminated sc-TdP in all patients, with no recurrence at mean 2.7 years (range 6 months to 8 years) of follow-up. Conclusion 3D-mapping and intracardiac echocardiography demonstrate that sc-TdP predominantly originates from the MB free wall insertion and its Purkinje network. Catheter ablation of the culprit PVC at the MB free wall junction leads to excellent short- and long-term results and should be considered as first-line therapy in recurrent sc-TdP or electrical storm
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