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  • br Disclosures and funding sources br Conflicts of interest

    2019-05-16


    Disclosures and funding sources
    Conflicts of interest
    Introduction In 1994, Leenhardt et al. first described electrocardiogram (ECG) findings of torsades de pointes and QT prolongation in patients without demonstrable structural Ro 31-8220 methanesulfonate Supplier disease, with the torsades de pointes initiated by short-coupled ventricular beats [1]. Some recent reports showed that premature ventricular beats (PVBs) from the distal Purkinje system, which occasionally occur with a short coupling interval, triggered polymorphic ventricular tachycardia (VT) or ventricular fibrillation (VF) [2,3]. On the other hand, in 2008, Haïssaguerre et al. reported an association between inferolateral early repolarization (ER), also called the J wave, and unexplained sudden cardiac death [4]. Since then, inferolateral ER has been identified as a marker of arrhythmic risk in the general population. However, risk assessment remains to be elucidated, since the prevalence of inferolateral ER in the general population is high and most individuals with this ECG pattern have a benign prognosis. Here, we report a case of idiopathic VF (IVF) with PVBs originating in the Purkinje system, occasionally with a short coupling interval, and ER in the inferolateral leads.
    Case presentation
    Discussion Haïssaguerre et al. [2] reported that PVBs originating from the distal Purkinje system triggered VF or polymorphic VT in patients without structural heart disease. In this report, the coupling interval of the first initiating PVB of VF was relatively short (297±41ms), and the PVBs originated from both the left and right ventricles. Several reports described triggered activity, abnormal automaticity, or reentry as possible underlying mechanisms of IVF originating from the Purkinje system [1–3,5–8]. Verapamil is considered effective in preventing such arrhythmic events. On the other hand, Haïssaguerre et al. also reported that triggered PVBs of IVF with ER in the inferolateral leads, also called the J wave syndrome [9], originated from the left ventricular myocardium or Purkinje system [4]. They further reported that the characteristics of IVF Ro 31-8220 methanesulfonate Supplier with ER in the inferolateral leads included the following: (1) most of the patients were men; (2) they had a history of unexplained syncope or sudden cardiac arrest during sleep or at night; and (3) exercise testing or isoproterenol infusion consistently reduced or eliminated ER. In particular, during repetitive episodes of VF, isoproterenol infusion eliminated all arrhythmias when the sinus heart rate was increased above 120beats/min. By contrast, β-blockers accentuated repolarization abnormalities. Interestingly, in our case, although ER in the inferolateral leads was detected by ECG, other characteristics did not fit with the J wave syndrome [4]. For example, exercise testing and isoproterenol infusion consistently reduced ER but frequently produced PVBs or NSVT, and the VF was initiated in the daytime. Furthermore, triggered PVBs originated from the right ventricular Purkinje system, not the left ventricular Purkinje system. We consider the underlying etiology of this case to be short-coupled PVB-related VT/VF rather than ER-related VT/VF, because PVBs or NSVTs were decreased by verapamil and propranolol infusion but increased by isoproterenol infusion, indicating triggered activity as the underlying mechanism [8,10]. Reentry was also related to the partial underlying mechanism of this case, as indicated by the complete disappearance of NSVT and PVB couplets despite the remaining trigger PVBs [2,3,8].
    Limitations
    Conflict of interest
    Introduction The use of MDCT or MRI in atrial fibrillation (AF) patients has been recommended in the preoperative anatomical determination of the left atrium-pulmonary veins before catheter ablation because of the local variation among patients [1]. In the current case report, we present the case of a rare anomalous muscular band originating from the left atrium and obstructing the ablation procedure.