Compartmentalized Structure of the Moderator Band Provides a Unique Substrate for Macroreentrant Ventricular Tachycardia

Walton, Richard D.; Pashaei, Ali; Martinez, M.; Constantin, Marion; Duchâteau, Josselin; Bear, Laura; Cros, Caroline; Pascarel-Auclerc, Caroline; Guo, Yun-Bo; Benoist, David; Dubes, Virginie; Faye, Ndeye Rokhaya; Chaigne, Sébastien; Dupuis, Sébastien; Détaille, Dominique; Pourtau, Line; Pasdois, Philippe; Brette, Fabien; Rogier, Julien; Labrousse, Louis; Hocini, Mélèze; Vigmond, Edward J.; Haı̈ssaguerre, Michel; Bernus, Olivier

doi:10.1161/circep.117.005913

Cited by 19 publications

(19 citation statements)

References 36 publications

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“…Structurally the MB is highly organised, composed of rapidly conducting specialised Purkinje fibres surrounded by ventricular myocytes. [ 14 , 15 ] The Purkinje fibres are insulated from surrounding ventricular myocardium by collagen and adipose tissue until peripheral arborisation along the RV-free wall ( Figure 1 ). [ 14 , 16 ] There is considerable inter-individual variability in thickness and the ratio of muscle to Purkinje fibre that is likely a determinant of the proarrhythmic potential of the MB.…”

Section: Anatomy and Electrophysiology Of The Moderator Bandmentioning

confidence: 99%

“…[ 14 , 16 ] There is considerable inter-individual variability in thickness and the ratio of muscle to Purkinje fibre that is likely a determinant of the proarrhythmic potential of the MB. [ 15 ] There are multiple mechanisms by which the MB participates in arrhythmias ( Figure 2 ). [ 16 ]…”

Section: Anatomy and Electrophysiology Of The Moderator Bandmentioning

confidence: 99%

“…In the sheep and human wedge preparations Walton et al demonstrated shorter refractory periods in the Purkinje fibres of the MB compared to surrounding myocardium and were able to demonstrate macro-re-entry between the RV free wall and the interventricular septum. [ 15 ] Whether such a macro-re-entrant mechanism is operative in the clinical arrhythmias involving the MB is unclear. In the series by Sadek et al, one patient has recurrent monomorphic VT triggering ICD shocks and that was ablated successfully in region between the MB and free wall insertion.…”

Section: Anatomy and Electrophysiology Of The Moderator Bandmentioning

confidence: 99%

“…14,16 There is considerable inter-individual variability in thickness and the ratio of muscle to Purkinje fibre that is likely a determinant of the proarrhythmic potential of the MB. 15 There are multiple mechanisms by which the MB participates in arrhythmias ( Figure 2). 16 In most ventricular arrhythmias implicating the MB, Purkinje potentials are often demonstrable preceding the onset of arrhythmia and dissociation or abolition of the potential is a marker for successful suppression of arrhythmias.…”

mentioning

confidence: 99%

“…20 interventricular septum. 15 Whether such a macro-re-entrant mechanism is operative in the clinical arrhythmias involving the MB is unclear. In the series by Sadek et al, one patient has recurrent monomorphic VT triggering ICD shocks and that was ablated successfully in region between the MB and free wall insertion.…”

mentioning

confidence: 99%

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Arrhythmias from the Right Ventricular Moderator Band: Diagnosis and Management

Barber

Chinitz

John

2020

Arrhythm Electrophysiol Rev

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The moderator band in the right ventricle is being increasingly recognised as a source for arrhythmias in the absence of identifiable structural heart disease. Because it carries part of the conduction system from the right ventricle septum to the free wall, it is a source of Purkinje-mediated ventricular arrhythmias that manifest as premature ventricular contractions (PVC) or repetitive ventricular tachycardia. More importantly, short coupled PVCs triggering polymorphic ventricular tachycardia and VF have been localised to the moderator band and ablation of these Purkinje mediated PVCs can effectively prevent recurrent VF. The exact mechanism of arrhythmogenesis is still debated but stretch, fibrosis and ion channel alterations might be responsible. Arrhythmias originating in this region of the right ventricle may thus be another cause for idiopathic VF that is potentially treatable with catheter-based ablation techniques. Recognition of the typical PVC morphology can point to the moderator band as the source of idiopathic VF and an opportunity for timely intervention. The available data on the anatomy, electrophysiology and management options are reviewed.

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Section: Anatomy and Electrophysiology Of The Moderator Bandmentioning

confidence: 99%

Section: Anatomy and Electrophysiology Of The Moderator Bandmentioning

confidence: 99%

Section: Anatomy and Electrophysiology Of The Moderator Bandmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Arrhythmias from the Right Ventricular Moderator Band: Diagnosis and Management

Barber

Chinitz

John

2020

Arrhythm Electrophysiol Rev

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Catheter ablation of short-coupled variant of torsade de pointes

et al. 2021

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Background The short-coupled variant of torsade de pointes (sc-TdP) is a malignant arrhythmia that frequently presents with ventricular fibrillation (VF) electrical storm. Verapamil is considered the first-line therapy of sc-TdP while catheter ablation is not widely adopted. The aim of this study was to determine the origin of sc-TdP and to assess the outcome of catheter ablation using 3D-mapping. Methods and results We retrospectively analyzed five patients with sc-TdP who underwent 3D-mapping and ablation of sc-TdP at five different institutions. Four patients initially presented with sudden cardiac arrest, one patient experienced recurrent syncope as the first manifestation. All patients demonstrated a monomorphic premature ventricular contraction (PVC) with late transition left bundle branch block pattern, superior axis, and a coupling interval of less than 300 ms. triggering recurrent TdP and VF. In four patients, the culprit PVC was mapped to the free wall insertion of the moderator band (MB) with a preceding Purkinje potential in two patients. Catheter ablation using 3D-mapping and intracardiac echocardiography eliminated sc-TdP in all patients, with no recurrence at mean 2.7 years (range 6 months to 8 years) of follow-up. Conclusion 3D-mapping and intracardiac echocardiography demonstrate that sc-TdP predominantly originates from the MB free wall insertion and its Purkinje network. Catheter ablation of the culprit PVC at the MB free wall junction leads to excellent short- and long-term results and should be considered as first-line therapy in recurrent sc-TdP or electrical storm. Graphic abstract

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3D magnetization transfer (MT) for the visualization of cardiac free-running Purkinje fibers: an ex vivo proof of concept

Magat

Fouillet

Constantin

et al. 2021

Magn Reson Mater Phy

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Objectives We investigate the possibility to exploit high-field MRI to acquire 3D images of Purkinje network which plays a crucial role in cardiac function. Since Purkinje fibers (PF) have a distinct cellular structure and are surrounded by connective tissue, we investigated conventional contrast mechanisms along with the magnetization transfer (MT) imaging technique to improve image contrast between ventricular structures of differing macromolecular content. Methods Three fixed porcine ventricular samples were used with free-running PFs on the endocardium. T1, T2*, T2, and M0 were evaluated on 2D slices for each sample at 9.4 T. MT parameters were optimized using hard pulses with different amplitudes, offset frequencies and durations. The cardiac structure was assessed through 2D and 3D T1w images with isotropic resolutions of 150 µm. Histology, immunofluorescence, and qPCR were performed to analyze collagen contents of cardiac tissue and PF. Results An MT preparation module of 350 ms duration inserted into the sequence with a B1 = 10 µT and frequency offset = 3000 Hz showed the best contrast, approximately 0.4 between PFs and myocardium. Magnetization transfer ratio (MTR) appeared higher in the cardiac tissue (MTR = 44.7 ± 3.5%) than in the PFs (MTR = 25.2 ± 6.3%). Discussion MT significantly improves contrast between PFs and ventricular myocardium and appears promising for imaging the 3D architecture of the Purkinje network.

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Compartmentalized Structure of the Moderator Band Provides a Unique Substrate for Macroreentrant Ventricular Tachycardia

Cited by 19 publications

References 36 publications

Arrhythmias from the Right Ventricular Moderator Band: Diagnosis and Management

Arrhythmias from the Right Ventricular Moderator Band: Diagnosis and Management

Catheter ablation of short-coupled variant of torsade de pointes

3D magnetization transfer (MT) for the visualization of cardiac free-running Purkinje fibers: an ex vivo proof of concept

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