Ventricular tachycardia due to sustained bundle branch reentry: diagnostic and therapeutic considerations

We have identified bundle-branch reentry (BBR) as the mechanism of ventricular tachycardia (VT) during electrophysiologic studies in 48 patients at our institution. All but three patients had significant structural heart disease, that is, dilated ischemic or idiopathic cardiomyopathy, the most common of anatomic substrates. Syncope and sudden death were the modes of presentation in up to 70% of these patients. The critical prerequisite for the development of this arrhythmia is conduction delay in the His-Purkinje system, which was present in all patients and manifests as a nonspecific conduction delay or a left bundle-branch block (LBBB) in the surface electrocardiogram (ECG) and a prolonged HV interval in the intracardiac recordings. VT with an LBBB morphology is the most common form of BBR, present in 98% of patients. Transcatheter ablation of the right bundle branch (RBB) with the use of radiofrequency current is the treatment of choice, as it effectively eliminates BBR. During long-term follow-up, recurrent tachycardia due to BBR was not documented in any patient; however, congestive heart failure was a common cause of death in this population.