Purkinje-related arrhythmias part ii: polymorphic ventricular tachycardia and ventricular fibrillation

There has been growing evidence that the Purkinje network plays a pivotal role in both the initiation and perpetuation of ventricular fibrillation (VF). A triggering ventricular premature beat (VPB) with a short-coupling interval could arise from either the right or left Purkinje system in patients with polymorphic ventricular tachycardia (VT) or VF, and that can be suppressed by the catheter ablation of the trigger. A focal breakdown in the "gating mechanism" at the Purkinje system resulting in a short-circuiting of the transmission across the gate at the distal Purkinje network might predispose to reentrant circuits of polymorphic VT/VF. Many investigators also reported the successful ablation of Purkinje-related VF with an acute or remote myocardial infarction. The same approach with good short-term results has been reported in a small number of patients with other heart diseases (i.e., amyloidosis, chronic myocarditis, nonischemic cardiomyopathy). Catheter ablation of the triggering VPBs from the Purkinje system can be used as an electrical bailout therapy in patients with VF storm.