©2017, original version available at: http://dx.doi.org/10.1016/j.hrcr.2016.12.005
Creative Commons Attribution License 4.

Khan, Arfaat

Lahiri, Marc K

Schuger, Claudio

Singh, Gurjit

English

Henry Ford Health System Scholarly Commons

Henry Ford Health System Henry Ford Health System Scholarly Commons Cardiology Articles Cardiology/Cardiovascular Research 3-1-2017 Bundle branch reentrant ventricular tachycardia after transcatheter aortic valve replacement. Gurjit Singh Henry Ford Health System, GSINGH1@hfhs.org Marc K. Lahiri Henry Ford Health System, MLAHIRI1@hfhs.org Arfaat Khan Henry Ford Health System, Akhan2@hfhs.org Claudio Schuger Henry Ford Health System, CSCHUGE1@hfhs.org Follow this and additional works at: https://scholarlycommons.henryford.com/cardiology_articles Recommended Citation Singh G, Lahiri MK, Khan A, Schuger CD. Bundle branch reentrant ventricular tachycardia after transcatheter aortic valve replacement. HeartRhythm Case Reports. 2017;3(3):177-185. This Article is brought to you for free and open access by the Cardiology/Cardiovascular Research at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Cardiology Articles by an authorized administrator of Henry Ford Health System Scholarly Commons. Bundle branch reentrant ventricular tachycardia aftertranscatheter aortic valve replacementGurjit Singh, MD, Marc K. Lahiri, MD, FACC, Arfaat Khan, MD,Claudio D. Schuger, MD, FACC, FHRSFrom the Section of Cardiac Electrophysiology, Henry Ford Heart and Vascular Institute, Henry FordHospital, Detroit, Michigan.IntroductionBundle branch reentrant ventricular tachycardia (BBR-VT)is a well-described entity that accounts for 6% of induciblesustained monomorphic VT during electrophysiology stud-ies.1 BBR-VT is a macroreentrant VT involving the His-Purkinje system and usually requires some form of con-duction delay in the His-Purkinje axis.2 BBR-VT is com-monly seen in patients with nonischemic dilatedcardiomyopathy, myotonic dystrophy,3 hypertrophic cardi-omyopathy, and valvular heart disease. Rare case reportshave been published involving patients after correctivesurgical aortic valve and mitral valve replacement withouta clear cause–effect relationship.2 Transcatheter aortic valvereplacement (TAVR) procedure is now a well-establishedpercutaneous procedure for patients with symptomaticsevere aortic stenosis who are deemed at high risk for atraditional surgical aortic valve replacement. Conductionabnormalities post TAVR have been well described, withhigh incidence of permanent pacemaker implantation.4TAVR procedure requiring valvuloplasty and stented valveis likely to affect the conduction system, possibly creatingthe right milieu for bundle branch reentry. We describe thefirst case of proven BBR-VT in a patient after TAVR, and itsmanagement with catheter ablation.Case reportA 75-year-old man with hypertension, obesity, insulin-dependent diabetes mellitus, paroxysmal atrial fibrillation,coronary artery disease status post coronary artery bypassgraft surgery (26 years ago), and severe aortic stenosis wasreferred to our institution for TAVR. He was deemed to be atmoderate risk for surgical valve replacement (Society ofThoracic Surgeons mortality estimate: 4.3%). His ejectionfraction was 50% on an echocardiogram, and a cardiaccatheterization prior to valve replacement showed stablecoronary artery disease with patent grafts along with a meantransaortic valve gradient of 48 mm Hg. He underwentsuccessful implantation of a 29-mm Edward-Sapien XTaortic prosthesis via the transfemoral approach. His electro-cardiogram (ECG) prior to valve replacement showed sinusrhythm with first-degree atrioventricular (AV) block andQRS duration of 120 ms (Figure 1A). A QR pattern in leadV1 was noted along with left axis deviation. An ECG a dayafter TAVR showed sinus rhythm with a long first-degreeAV block and left bundle branch block (LBBB) (Figure 1B).He presented 2 weeks later with palpitations, dizziness, andrecurrent presyncopal episodes when he was noted to haveincessant wide complex left bundle branch (LBB) tachycar-dia at 200 beats per minute (Figure 1C). QRS morphology ofthe tachycardia resembled pre-existing LBBB morphologywith late precordial R/S transition and QRS axis of 29degrees. Given highly symptomatic status during the tachy-cardia, he received multiple synchronized cardioversions andwas started on amiodarone infusion. He was taken to theelectrophysiology laboratory in fasting state and standardintracardiac catheters were introduced. A long HV interval of88 ms (Figure 1D) was recorded from the His bundle catheterplaced across the tricuspid valve, and 1:1 AV conductionwas documented to 620 ms. No ventriculoatrial conductionwas noted at baseline or during isoproterenol infusion.Programmed electrical stimulation from the right ventricle(RV) apex using triple extrastimuli was performed, whichreproducibly induced ventricular fibrillation requiring exter-nal defibrillation. No clinical tachycardia was induced at thisstudy session. Given the presence of coronary artery disease,mildly reduced ventricular function, underlying conductionabnormality, and induction of ventricular fibrillation, a dual-chamber internal cardioverter-defibrillator (ICD) wasimplanted.The day after the ICD implant, the patient developedmultiple episodes of wide complex tachycardia associatedwith AV dissociation, some of them pace terminated andKEYWORDS Bundle branch reentrant ventricular tachycardia; Transcatheteraortic valve replacement; Catheter ablation(Heart Rhythm Case Reports 2017;3:177–185)Address reprint requests and correspondence: Dr Gurjit Singh, SeniorStaff Physician, Section of Cardiac Electrophysiology, Henry Ford Hospital,2799 West Grand Boulevard, Detroit, MI 48202. E-mail address:gsingh1@hfhs.org.2214-0271 B 2017 Heart Rhythm Society. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.hrcr.2016.12.005some requiring ICD shocks. Antitachycardia pacing wasalways successful in terminating the tachycardia immedi-ately. One of the episodes of VT degenerated into ventricularfibrillation, which required ICD therapy. The patient wastaken back to the electrophysiology laboratory while inincessant wide complex tachycardia. Two quadripolar cath-eters were advanced to the RV apex and the His bundle area.A decapolar mapping catheter was placed along the RVseptum, given the suspicion of a BBR-VT. A right bundle(RB) potential preceding every QRS complex was noted(Figure 2A). Obtaining a His bundle electrogram waschallenging during sinus rhythm as well as during tachycar-dia. Overdrive pacing from the RV apex led to entrainmentwith manifest fusion and a postpacing interval within 30 msof the tachycardia cycle length, which supported diagnosis ofBBR-VT (Figure 2B). Progressive fusion was demonstrated,with faster overdrive pacing cycle lengths supporting areentrant mechanism. Spontaneous variation in RB-RBinterval preceded changes in R-R interval. A diagnosis ofBBR-VT was made with RB being the antegrade limb basedon entrainment criteria, presence of prolonged His-Purkinjeconduction, and QRS morphology. Radiofrequency ablationusing an irrigated-tip catheter was performed during VT,targeting the RB potential. Ablation was performed at 40 W,which led to termination of the VT (Figure 2C-E). Furtherablation lesions were delivered targeting the RB, which ledto complete AV block and paced ventricular rhythm.Aggressive programmed ventricular stimulation confirmednoninducibility of clinical tachycardia. The patient wasdischarged home and presented for routine postimplantfollow-up after a week. During the visit, it was observedthat the patient regained AV conduction with evidence ofLBBB on the ECG. During threshold testing of the rightventricular lead, the patient developed an episode of VT,which was easily terminated by antitachycardia pacing(Figure 3A). The patient was brought back to the electro-physiology laboratory and diagnostic maneuvers againconfirmed BBR-VT due to recovery of conduction via theright bundle branch (RBB). Repeat ablation of the RB wasperformed during VT, which led to termination of the VT.Post ablation, the patient developed transient complete AVblock followed by antegrade conduction exclusively via theLBB, as evident by the now complete RBB block on ECG(Figure 3B). VT noninducibility was again confirmed andthe patient has remained arrhythmia free at 18 monthsfollow-up without need for any antiarrhythmic medications.DiscussionWe report a case of BBR-VT in an elderly patient with anondilated, normally functioning left ventricle and coronaryartery disease after undergoing TAVR procedure for aorticstenosis. To the best of our knowledge, BBR-VT afterTAVR has not been reported previously.BBR-VT is usually described in patients with cardiomyop-athy and some form of chronic conduction defect usuallyassociated with a long HV interval.5 Wide QRS tachycardiawith LBBB morphology is the most common form of BBR-VTencountered in clinical practice, in which the RBB serves as theantegrade limb, the left bundle serves as the retrograde limb,and the interventricular septum provides the connecting link.BBR-VTwith RBB configuration, where the reverse sequence ofactivation occurs, is encountered less commonly.Most of the cases of BBR-VT are seen in patients withstructural heart disease, but multiple case reports exist in theliterature in patients with structurally normal hearts.6 BBR-VT has been described secondary to flecainide use,7 Brugadapattern,8 and AV block.9 Conduction abnormalities arecommon in valvular heart disease owing to associatedventricular dilatation and calcification of the valvularannuli.10 Anatomic-pathologic studies have revealed thatthe weakest portion of the LBB system is at the junction ofthe main His bundle and LBB at the level of parsmembranacea and LV summit, where infarction/fibrosisand calcification are seen.11 We believe that the presenceof aortic calcification and stretch induced from a deeplyseated TAVR prosthesis worsened the His-Purkinje con-duction and generated the right milieu for this form ofreentry.BBR-VT after aortic or mitral valve surgery has beenstudied by Calambur et al in 31 patients, with 9 cases (30%)documented at a median time of 10 days postoperatively.10The patient in this cohort had baseline prolonged PRintervals, long HV interval, and relatively preserved leftventricular function. Our case presented within a week postTAVR procedure, which supports the fact that the valvereplacement procedure, either surgically or percutaneously,leads to His-Purkinje system conduction delays that canKEY TEACHING POINTS Patients after transcatheter aortic valvereplacement (TAVR) can present with presyncope/syncope related to ventricular tachycardia besidesAV block. TAVR creates the right milieu of His-Purkinje conduction delay, which can allow bundlebranch reentrant ventricular tachycardia (BBR-VT). His bundle recordings during BBR-VT are anessential component for the appropriate diagnosis,but obtaining a discernible His bundle electrogrammay be extremely challenging in patients postTAVR. Recording right bundle (RB) branch potentialpreceding each QRS, ventriculoatrial dissociation,and changes in RB-RB intervals during tachycardiawobble, along with entrainment maneuvers, ishelpful in reaching the appropriate diagnosis. Bundle branch block after aortic valve replacementmay be attributable to incomplete transection ofthe left bundle fibers, as evident by development ofRB branch block post ablation of RB in patientswith BBR-VT.Heart Rhythm Case Reports, Vol 3, No 3, March 2017178precipitate reentrant VT. Our patient did not have anysymptoms of palpitations or presyncope prior to TAVRprocedure.A case report of VT originating from the aortomitralcontinuity region in a patient with transapical TAVR hasbeen reported, but no confirmatory electrophysiology studyFigure 1 A: Twelve-lead electrocardiogram (ECG) depicting sinus rhythm with first-degree atrioventricular block and a QRS duration of 120 ms.B: Twelve-lead ECG after transcatheter aortic valve replacement demonstrating sinus rhythm with severely prolonged PR interval (340 ms) and left bundlebranch block (LBBB), QRS duration (180 ms). C: ECG showing wide complex tachycardia with LBBB morphology, late precordial transition, and normalfrontal plane axis at 200 beats per minute. D: Baseline intracardiac measurements reveal HV interval of 88 ms.179Singh et al Bundle Branch Reentrant VT After TAVRwas performed in the patient.12 BBR-VT after TAVR has notbeen reported to date.BBR-VT should be in the differential diagnosis ofpatients undergoing TAVR procedure who present withpresyncope or syncope. If patients are noted to have worsen-ing of AV conduction system post TAVR, as evidenced byprolongation of PR interval or the development of bundlebranch block, consideration should be given to evaluate forFigure 1 ContinuedHeart Rhythm Case Reports, Vol 3, No 3, March 2017180Figure 2 A: Intracardiac electrograms showing ventriculoatrial dissociation and right bundle (RB) potential preceding each QRS during left bundle branchtachycardia (PR 1–10 refers to decapolar navigation catheter signals across the right ventricle [RV] septum). B: Overdrive pacing from RV apex at 320 ms led toentrainment with manifest fusion and postpacing interval tachycardia cycle length (PPI-TCL) of 17 ms. C: A pre-QRS right bundle (RB) potential is noted onablation catheter during tachycardia. D: Radiofrequency ablation at the site of recorded RB potential led to termination of ventricular tachycardia.E: Fluoroscopy image (right anterior oblique 29 degrees) showing location of ablation catheter on RV septum and relationship to aortic prosthesis.181Singh et al Bundle Branch Reentrant VT After TAVRFigure 2 ContinuedHeart Rhythm Case Reports, Vol 3, No 3, March 2017182BBR-VT if the patient presents with palpitations or syncope.Consideration should also be given to using short-long-shortsequences during programmed electrical stimulation toinduce BBR-VT.Catheter ablation of RBB is curative for typical BBR-VTbut can lead to development of complete block or furtherworsening of AV conduction, often requiring permanentpacemaker implant.13 Although catheter ablation of LBB hasbeen reported in a patient with baseline LBBB,14 presence ofalready prolonged infra-Hisian conduction and aortic pros-thesis in our patient justified ablation of RBB for treatment ofBBR-VT.Although ECG of patients presenting with BBR-VTusually shows nonspecific intraventricular conduction delayor typical bundle branch block, the fact that our patientshowed AV conduction via the LBB (manifested by com-plete RBB block on ECG) post ablation points to the conceptthat conduction in bundle branches is relatively delayed toeach other rather than completely interrupted. This concepthas been nicely studied by Schmidt et al, where electro-anatomic mapping of left sided His-Purkinje system inpatients with LBBB presenting with BBR-VT showed absentconduction via the left anterior fascicle and slowed con-duction via the posterior fascicle.15Our case highlights the fact that patients after TAVR canpresent with sudden presyncope/syncope, which can beFigure 2 ContinuedFigure 3 A: Tachycardia noted during internal cardioverter-defibrillator interrogation, which initiated after a short-long-short sequence and was terminated byantitachycardia pacing. B: Electrocardiogram showing sinus rhythm with right bundle branch (RBB) block post ablation of RBB, reflecting conduction via theleft bundle branch. C: Echocardiogram image in parasternal long-axis view showing deep-seated Edward-Sapien 29-mm aortic prosthesis.183Singh et al Bundle Branch Reentrant VT After TAVRattributed to BBR-VT besides AV block. It is likely that thelocation of aortic prosthesis at the time of deployment plays arole in causing damage to the conduction system. Our patienthad the prosthetic valve seated deep in the left ventricularoutflow tract, as evident on echocardiogram (Figure 3C).ConclusionsAV nodal and/or His-Purkinje conduction delay is com-monly seen after percutaneous TAVR in patients with severeaortic stenosis, which can create the right milieu for develop-ment of BBR-VT. Catheter ablation of the RB is curative inFigure 3 ContinuedHeart Rhythm Case Reports, Vol 3, No 3, March 2017184treatment of BBR-VT but requires permanent pacing supportowing to already slowed AV nodal or infra-Hisian conduc-tion. BBR-VT should be considered in the differentialdiagnosis of patients presenting with palpitations/syncopein the postoperative period after TAVR.References1. Balasundaram R, Rao HB, Kalavakolanu S, Narasimhan C. Catheter ablation ofbundle branch reentrant ventricular tachycardia. Heart Rhythm 2008;5:S68–S72.2. Eckart RE, Hruczkowski TW, Tedrow UB, Koplan BA, Epstein LM, StevensonWG. Sustained ventricular tachycardia associated with corrective valve surgery.Circulation 2007;116:2005–2011.3. Ramirez CJ, Rodriguez DA, Velasco VM, Rosas F. Myotonic dystrophy andbundle-branch re-entrant tachycardia. Rev Esp Cardiol 2002;55:1093–1097.4. Maan A, Refaat MM, Heist EK, Passeri J, Inglessis I, Ptaszek L, Vlahakes G,Ruskin JN, Palacios I, Sundt T, Mansour M. Incidence and predictors ofpacemaker implantation in patients undergoing transcatheter aortic valve replace-ment. Pacing Clin Electrophysiol 2015;38:878–886.5. Caceres J, Jazayeri M, McKinnie J, Avitall B, Denker ST, Tchou P, Akhtar M.Sustained bundle branch reentry as a mechanism of clinical tachycardia.Circulation 1989;79:256–270.6. Fynn SP, Kalman JM. Bundle branch reentrant tachycardia in a patient withnormal ventricular function. J Interv Card Electrophysiol 2004;10:255–259.7. Saoudi N, Berland J, Cribier A, Letac B. Bundle branch reentry tachycardia: apossible mechanism of flecainide proarrhythmia effect. Arch Mal Coeur Vaiss1988;81:537–541.8. Mazur A, Iakobishvili Z, Kusniec J, Strasberg B. Bundle branch reentrantventricular tachycardia in a patient with the Brugada electrocardiographic pattern.Ann Noninvasive Electrocardiol 2003;8:352–355.9. Irtel TA, Delacretaz E. Bundle branch re-entry ventricular tachycardia in a patientwith complete heart block. Europace 2006;8:613–615.10. Narasimhan C, Jazayeri MR, Sra J, Dhala A, Deshpande S, Biehl M, Akhtar M,Blanck Z. Ventricular tachycardia in valvular heart disease: facilitation ofsustained bundle-branch reentry by valve surgery. Circulation 1997;96:4307–4313.11. Lev M, Unger PN, Rosen KM, Bharati S. The anatomic substrate of complete leftbundle branch block. Circulation 1974;50:479–486.12. Beinart R, Danik S, Palacios I, Barrett C, Inglessis I, Agnihotri A, Passeri J.Ventricular tachycardia following trans-apical aortic valve replacement. Euro-pace 2012;14:450–452.13. Cohen TJ, Chien WW, Lurie KG, et al. Radiofrequency catheter ablation fortreatment of bundle branch reentrant ventricular tachycardia: results and long-term follow-up. J Am Coll Cardiol 1991;18:1767–1773.14. Blanck Z, Deshpande S, Jazayeri MR, Akhtar M. Catheter ablation of the leftbundle branch for the treatment of sustained bundle branch reentrant ventriculartachycardia. J Cardiovasc Electrophysiol 1995;6:40–43.15. Schmidt B, TangM, Chun KR, Antz M, Tilz RR, Metzner A, Koektuerk B, Xie P,Kuck KH, Ouyang F. Left bundle branch-Purkinje system in patients with bundlebranch reentrant tachycardia: lessons from catheter ablation and electroanatomicmapping. Heart Rhythm 2009;6:51–58.185Singh et al Bundle Branch Reentrant VT After TAVR

Bundle branch reentrant ventricular tachycardia after transcatheter aortic valve replacement

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Bundle branch reentrant ventricular tachycardia after transcatheter aortic valve replacement

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