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Sinus Rhythm

Fig. 3. Diagnosis and ablation of bundle-branch reentrant tachycardia is shown. In panel A, bundlebranch reentry tachycardia initiated in the electrophysiology laboratory is shown. Tachycardia has a LBBB configuration and cycle length of 295 ms. AV dissociation is evident in the right atrial recording (RA). A His bundle deflection (H) precedes each QRS, indicating that the His-Purkinje system is closely linked to the tachycardia. The mechanism is illustrated in the schematic at the right. In panel B, the ablation catheter has been placed distal to the His bundle, where the RBB potential is recorded. The H-V interval is 60 ms and the right bundle-V interval is 35 ms. In panel C, RF ablation of the RBB is performed. Radiofrequency current application causes transient accelerated automaticity of the RBB, inscribing three PVCs with a LBBB pattern. Then, RBBB is present (arrow). This interrupts the reentry circuit as illustrated in the schematic above the tracing. RBBB = right bundle branch.

Sinus Rhythm

Fig. 3. Diagnosis and ablation of bundle-branch reentrant tachycardia is shown. In panel A, bundlebranch reentry tachycardia initiated in the electrophysiology laboratory is shown. Tachycardia has a LBBB configuration and cycle length of 295 ms. AV dissociation is evident in the right atrial recording (RA). A His bundle deflection (H) precedes each QRS, indicating that the His-Purkinje system is closely linked to the tachycardia. The mechanism is illustrated in the schematic at the right. In panel B, the ablation catheter has been placed distal to the His bundle, where the RBB potential is recorded. The H-V interval is 60 ms and the right bundle-V interval is 35 ms. In panel C, RF ablation of the RBB is performed. Radiofrequency current application causes transient accelerated automaticity of the RBB, inscribing three PVCs with a LBBB pattern. Then, RBBB is present (arrow). This interrupts the reentry circuit as illustrated in the schematic above the tracing. RBBB = right bundle branch.

be particularly suspected in patients who have sustained monomorphic VT associated with valvular heart disease (36), cardiomyopathy, or muscular dystrophy (37,38), in which a discrete region of myocardial scarring that could be an arrhythmia focus is absent. Most patients have severely depressed left ventricular function accompanying the His-Purkinje system disease. The tachycardia is often rapid (average rate of approx 215 beats per minute (BPM)), often causing syncope or cardiac arrest.

Bundle-branch reentrant tachycardia is easily cured by radiofrequency ablation of the RBB, which interrupts the circuit (32,39) (Fig. 3). The right bundle can be located by placing the catheter at the His bundle position, and then advancing the catheter distally from that point to the location where the potential from the RBB is recorded. Although curative, ablation of the RBB may further compromise atrioventricular (AV) conduction. A permanent pacemaker is recommended if the HV interval is markedly prolonged (>90 ms) after ablation of the RBB, and is required in up to 20-30%. Some patients, particularly those with prior MI, have scar-related VTs in addition to bundlebranch reentry; implantation of a defibrillator is usually considered. Patients with bundlebranch reentry associated with severely impaired ventricular dysfunction have a high mortality because of death from progressive heart failure (32,35).

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How To Reduce Acne Scarring

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