Pleomorphic ventricular tachycardia with antegrade His-bundle activation: elucidation by multiple His-bundle recordings.

The use of multiple His bundle-right bundle branch recordings in electrophysiologic studies has facilitated definition of the mechanism and elucidation of the direction of impulse propagation in bundle branch reentrant tachycardia, "Mahaim" fiber reciprocating tachycardia, and retrograde His depolarization in fascicular or ventricular tachycardias. This report details the electrophysiologic evaluation of pleomorphic ventricular tachycardia in a patient with advanced coronary heart disease. The ventricular tachycardia at baseline revealed variation in the QRS duration without alteration of the electrocardiographic (ECG) morphology. Following flecainide administration, a ventricular tachycardia with close resemblance of the ECG morphology to sinus rhythm was induced. Proximal and distal His-bundle recordings revealed early antegrade His-bundle activation during this tachycardia. Programmed stimulation converted this tachycardia back to the clinical ventricular tachycardia with intermittent narrowing of the QRS complexes. Early His activation was evident only during the narrower complexes but not in the tachycardia beats with wide complex. Penetration of the His bundle by ventricular tachycardia, with resultant fusion from intramyocardial ventricular activation and His-Purkinje activation, could have accounted for the near normalization of the QRS morphology during the ventricular tachycardia.