Mechanisms of torsade de pointes tachycardia in patients with spontaneous high-degree atrioventricular block: A modern look at old data

Abstract

IntroductionThe mechanisms of torsade de pointes tachycardia (TdP) are incompletely understood. We aimed to investigate the mechanisms underlying TdP tachycardia in patients with spontaneous high-degree atrioventricular block (AVB). Methods and resultsThis retrospective study reviewed old TdP recordings after ventricular temporary pacing interruption in 16 patients with spontaneous high-degree AVB. Five of them had also bipolar endocardial right ventricular (RV) apex recordings. The QT interval during AVB at a mean heart rate of 38.9 ± 7.5 bpm was 653.0 ± 67.2 ms. The critical coupling interval (CCI) between the last escape QRS during AVB and the first premature ventricular complex (PVC) was significantly shorter before the onset of TdP than before single PVCs and couplets. A morphologic crescendo of the escape T wave was observed before the onset of TdP, followed by a rhythmic and morphologic crescendo of PVCs. The escape RV apex electrograms (EGMs) showed the constant pattern of a rapid deflection similar to a Purkinje potential 40 to 80 ms after the onset of the QRS, superimposed on a smooth low amplitude signal in 4 out of 5 patients. ConclusionsThe major endocardial T wave prolongation and augmentation (morphologic crescendo) of the escape beat prior to the first PVC suggests a phase 2 reentry mechanism due to early afterdepolarization. The induced TdP can be due to the changing outputs from one or two simultaneous RV moving reentry circuits between depressed fibers and fast conducting ones, possibly located in the thin crista supraventricularis structure which has several connections with the septum and the RV free wall.