Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2025 Apr 10;11(6):503-508.
doi: 10.1016/j.hrcr.2025.04.005. eCollection 2025 Jun.

Electrophysiological impact of subgingival nicotine gum use in athletes: Completing the Coumel triangle in sustained ventricular tachycardia reentry

Konstantinos Vlachos  1 , Karim Benali  1   2 , John Fitzgerald  1 , Masaaki Yokoyama  1 , Allan Plant  1 , Kinan Kneizeh  1 , Nicolas Johner  1 , Laurens Verhaeghe  1 , Geoffroy Ditac  1 , Cinzia Monaco  1 , Romain Tixier  1 , Benjamin Bouyer  1 , Laurent Chevalier  3 , Josselin Duchateau  1 , Mélèze Hocini  1 , Michel Haïssaguerre  1 , Pierre Jaïs  1 , Frédéric Sacher  1
Affiliations
Case Reports

Electrophysiological impact of subgingival nicotine gum use in athletes: Completing the Coumel triangle in sustained ventricular tachycardia reentry

Konstantinos Vlachos et al. HeartRhythm Case Rep. .
No abstract available

Keywords: Coumel triangle; High-resolution mapping; PVS; Programmed ventricular stimulation; Pulsed field ablation; Radiofrequency Ablation; SNUS; Subgingival nicotine gum; VSD patch; VT reentry.

PubMed Disclaimer

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Programmed ventricular stimulation was performed after the administration of isoproterenol and nicotine. The protocol included a drive train of 8 beats at a cycle length of 380 ms, followed by 3 extrastimuli at 190/180/260 ms, with pacing delivered from the right ventricle near the scar of a prior right ventriculotomy. This protocol successfully induced sustained reentrant ventricular tachycardia (cycle length: 198 ms). The electrocardiogram demonstrated a left bundle branch block pattern, an inferior axis, and a transition zone at V4, consistent with a ventricular tachycardia exit site in the right ventricular outflow tract.
Figure 2
Figure 2
Α,Β: High-resolution activation mapping using the HD Grid multipolar catheter (Abbott, Chicago, IL) revealed the ventricular tachycardia (VT) exit site beneath the pulmonary valve in the right ventricular outflow tract region. The critical anatomic VT isthmus was localized between the pulmonary valve and the ventricular septal defect closure patch. High-resolution mapping, using the omnipolar algorithm, detected near-field potentials (electrograms B4, B3, A4, and C4, C3, B4) occurring 67 ms before QRS onset. The VT cycle length was 198 ms, consistent with the presence of mid-diastolic potentials within the VT isthmus.
Figure 3
Figure 3
Redo ablation performed using the Affera mapping system (Medtronic, Minneapolis, MN) in conjunction with pulsed field ablation technology achieving transmural lesions in the right ventricular outflow tract. The procedure aimed to create a conduction block extending from the pulmonary valve to the region of the ventricular septal defect closure patch, with the goal of disrupting potential reentrant circuits responsible for sustaining ventricular tachycardia. The conduction block was successfully achieved along the targeted line. To confirm bidirectional block, we performed high-resolution activation mapping during pacing basal-lateral to the line, as well as differential pacing maneuvers near the ablation line. Both approaches consistently demonstrated the presence of bidirectional conduction block across the ablation line.
See this image and copyright information in PMC

References

    1. Coumel P. The management of clinical arrhythmias. An overview on invasive versus non-invasive electrophysiology. Eur Heart J. 1987;8:92–99. - PubMed
    1. Haïssaguerre M., Jaïs P., Shah D.C., et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659–666. - PubMed
    1. Haïssaguerre M., Shah D.C., Jaïs P., et al. Role of Purkinje conducting system in triggering of idiopathic ventricular fibrillation. Lancet. 2002;359:677–678. - PubMed
    1. de Bakker J.M., van Capelle F.J., Janse M.J., et al. Slow conduction in the infarcted human heart. 'Zigzag' course of activation. Circulation. 1993;88:915–926. - PubMed
    1. Sung E., Prakosa A., Zhou S., et al. Fat infiltration in the infarcted heart as a paradigm for ventricular arrhythmias. Nat Cardiovasc Res. 2022;1:933–945. - PMC - PubMed

Publication types

LinkOut - more resources