Three-Dimensional Visualization of Bidirectional Preferential Pathway
Conduction of Premature Ventricular Contractions Originating from the
Outflow Tract
Abstract
Introduction: Presence of preferential pathway conduction is mostly
detected as fractionated presystolic potentials preceding the QRS onset
during premature ventricular contractions (PVCs) and late potentials
during sinus rhythm (SR), but the electrophysiologic mechanisms and
significance of these potentials have not been fully clarified. We
describe a PVC case series in which the preferential pathway conduction
was 3-dimensionaly visualized by coherent mapping with the conduction
velocity vector. Methods: Five PVCs (2 from the left coronary cusp, 2
from the commissure of the left and right coronary cusps, and 1 from the
pulmonary artery) in 4 patients for which a fractionated presystolic
potential during the PVCs and late potential during SR were recorded at
the successful ablation site were reviewed, and 3-dimensional coherent
activation maps with the conduction velocity vector during the PVCs and
SR were reconstructed. Results: At the successful ablation site, an
“M”-shaped discrete presystolic-potential and “W”-shaped discrete
late-potential were recorded in all patients. The configuration of the
flipped electrogram of the presystolic-potential nearly matched that of
the electrogram exhibiting the late-potential. We created coherent
activation maps annotating the onset of the presystolic potentials
during the PVCs, and the offset of the late potentials during SR, which
suggested bidirectional conduction of the preferential pathway
connecting the PVC origin to the myocardium. Conclusion: In this case
series, the M-shaped presystolic potential and W-shaped late potential
were reversely matched. These reverse potentials, and the coherent
activation vector maps during PVCs and SR suggested bidirectional
conduction of the preferential pathway in opposite directions.