Complex Re-Entrant Arrhythmias Involving the His-Purkinje System: A Structured Approach to Diagnosis and Management

Aleksandr Voskoboinik, Edward P. Gerstenfeld, Joshua D. Moss, Henry Hsia, Jeffrey Goldberger, Babak Nazer, Thomas Dewland, David Singh, Nitish Badhwar, Patrick J. Tchou, John N. Meriwether, William Sauer, Asaf Danon, Bernard Belhassen, Melvin M. Scheinman*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Objectives: This study sought to characterize the presentations, electrophysiological features and diagnostic maneuvers for a series of unique arrhythmias involving the HPS. Background: By virtue of its unique anatomy and ion channel composition, the His-Purkinje system (HPS) is prone to a variety of arrhythmic perturbations. Methods: The authors present a collaborative multicenter case series of 6 patients with HPS-related arrhythmias. All patients underwent electrophysiological studies using standard multipolar catheters. Results: In 3 patients, both typical and reverse bundle branch re-entry were seen, with 1 patient demonstrating “figure of 8” re-entry likely involving the septal fascicle. One patient presented with systolic dysfunction associated with a high premature ventricular complex burden, with the mechanism being bundle-to-bundle re-entrant beats masquerading as dual response to a single sinus impulse. Two patients were diagnosed with interfascicular re-entry. Diagnosis was aided by careful assessment of HV interval in sinus rhythm and ventricular tachycardia, multipolar catheters to assess the activation sequence of the His-right bundle branch, and fascicles and entrainment of different components of the HPS. Cure of the arrhythmia was achieved by ablation of the right bundle branch block in 3 patients, the left septal fascicle in 2 patients, and the left posterior fascicle in 1 patient. Conclusions: Proper diagnosis of re-entrant arrhythmias involving the HPS may prove challenging. We emphasize a structured approach for diagnosis and effective therapy.

Original languageEnglish
Pages (from-to)1488-1498
Number of pages11
JournalJACC: Clinical Electrophysiology
Issue number12
StatePublished - Nov 2020
Externally publishedYes


  • His-Purkinje
  • ablation
  • bundle branch re-entry
  • mapping
  • ventricular tachycardia


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