Circulation, Vol 83, 886-901, Copyright © 1991 by American Heart Association
J Liebman, JA Zeno, B Olshansky, AS Geha, CW Thomas, Y Rudy, RW Henthorn, M Cohen and AL Waldo
BACKGROUND. A reliable, noninvasive procedure to determine the location of
accessory atrioventricular connections in patients with Wolff-
Parkinson-White syndrome would add an important diagnostic tool to the
clinical armamentarium. METHODS AND RESULTS. Body surface potential mapping
(BSPM) using 180 electrodes in various-sized vests and displayed as a
calibrated color map was used to determine the ventricular insertion site
of the accessory atrioventricular (AV) connections in 34 patients with
Wolff-Parkinson-White syndrome. Attempts were made to determine the 17
ventricular insertion sites described by Guiraudon et al. All 34 patients
had an electrophysiologic study (EPS) at cardiac catheterization, and 18
had surgery so the ventricular insertion sites could be accurately located
using EPS at surgery. A number of physiologic observations were also made
with BSPM. CONCLUSIONS. The following conclusions were drawn: 1) BSPM using
QRS analysis accurately predicts the ventricular insertion site of
accessory AV connections in the presence of a delta wave in the
electrocardiogram; 2) the ventricular insertion sites of accessory AV
connections determined by BSPM and by EPS at surgery were identical or
within one mapping site (1.5 cm or less) in all but four of 18 cases; three
of the four exceptions had more than one accessory AV connection, and the
other had a very broad ventricular insertion; 3) BSPM and EPS locations of
the accessory AV connections correlated very well in the 34 cases despite
the fact that BSPM determines the ventricular insertion site and EPS
determines the atrial insertion site of the accessory AV connection; 4) as
suggested by the three cases of multiple accessory AV connections, EPS and
BSPM may be complementary since BSPM identified one pathway and EPS
identified the other (in the case with a broad ventricular insertion, BSPM
and EPS demonstrated different proportions of that insertion); 5) BSPM
using ST-T analysis is very much less accurate in predicting the
ventricular insertion site of accessory AV connections unless there is
marked preexcitation; 6) standard electrocardiography using the Gallagher
grid methodology (but with no attempt at stimulating maximal preexcitation)
was not as accurate as QRS analysis of BSPM in predicting the ventricular
insertion site of the accessory AV connection; however, exact comparison is
hampered by the different number and size of the Gallagher and Guiraudon
insertion sites; 7) BSPM using QRS analysis appears to be very accurate in
predicting right ventricular versus left ventricular posteroseptal
accessory AV connections; 8) typical epicardial right ventricular
breakthrough, indicative of conduction via the specialized AV conduction
system, occurs in all patients with left ventricular free wall accessory AV
connections; 9) epicardial right ventricular breakthrough was not observed
in cases with right ventricular free wall or anteroseptal accessory AV
connections; 10) epicardial right ventricular breakthrough can occur in the
presence of posteroseptal accessory AV connections, whether right or left
ventricular; and 11) the delay in epicardial right ventricular breakthrough
in cases with left ventricular insertion may provide a marker to estimate
the degree of ventricular preexcitation.
ARTICLES
Electrocardiographic body surface potential mapping in the Wolff- Parkinson-White syndrome. Noninvasive determination of the ventricular insertion sites of accessory atrioventricular connections
Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio.
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