Three‐dimensional visualization of bidirectional preferential pathway conduction of premature ventricular contractions originating from the outflow tract

Preferential pathway conduction is mostly detected as fractionated presystolic‐potentials preceding the QRS 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 three‐dimensionally visualized. Methods Five PVCs (two from the left coronary cusp, two from the commissure of the left and right coronary cusps, and one from the pulmonary artery) in four 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 three‐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 inverted electrogram of the presystolic‐potential was similar to that of the electrogram exhibiting the late‐potential. We created coherent activation maps annotating the onset of the presystolic‐potentials during the PVCs and offset of the late‐potentials during SR, which suggested bidirectional conduction of the preferential pathway connecting the PVC origin to the myocardium. Conclusion Detailed activation mapping of these PVCs is consistent with the presence of fibers along the aortic or pulmonic valve ring that have preferential directions for conduction. PVCs produce a presystolic‐potential. In SR, the fiber is activated late and from the opposite direction, producing an inverted potential inscribed on the end of the QRS.