Case Report: Pulsed field ablation of an oblique inferoparaseptal accessory pathway

Figures

• 

  Figure 1. 12-lead ECG of a 36-year-old man showing pre-excitation with negative delta wave in V1, absent in inferior leads, and positive in V3-consistent with right paraseptal accessory pathway per pambrun et al. (24).

• 

  Figure 2. Electrophysiology study. (A) Baseline sinus rhythm: earliest ventricular activation and maximal pre-excitation at proximal CS (9/10), suggesting a right-sided AP. (B) RV pacing: eccentric atrial activation, earliest at mid-CS (5/6), indicating a left-sided inferoparaseptal AP. (C,D) HD-Grid mapping (EnSite Precision): earliest atrial activation at the inferior interatrial septum near the CS roof (atrial insertion); (C) right anterior oblique (RAO) view, (D) left anterior oblique (LAO) view. (E) Schematic valvular plane with inferoparaseptal oblique AP (red tortuous line): atrial insertion at the inferior interatrial septum above the CS roof, ventricular exit inferoparaseptal on the left side. HIS: His bundle.

• 

  Figure 3. Pulsed field ablation (PFA) and outcome. (A,B) Centauri™ PFA system: multiple lesions from the inferior interatrial septum to the CS roof, achieving conduction block at the CS ostium/roof; (A) right anterior oblique (RAO) view, (B) left anterior oblique (LAO) view. (C) Successful AP ablation: no residual pre-excitation; atrial pacing for vagally induced bradycardia. (D) Reproducible Kent bundle potential (AP potential) recorded between local atrial and ventricular electrograms at the atrial insertion of an oblique posteroseptal accessory pathway (inferior interatrial septum/CS roof), with termination upon.

• 

  Figure 4. Post-procedure 12-lead ECGs: no pre-excitation evident, notable cardiac memory in III and aVF.