Importance of Polarity Reversal in Leads I/aVL in the Diagnosis of an Accessory Pathway Originating from the Aortomitral Continuity

Figures

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  Figure 1:. A: Initial ECG showing a Wolff–Parkinson–White pattern and AF. Note a positive delta/QRS wave in lead I and negative delta/QRS wave in lead aVL as well as qR in lead V1 and Rs in lead V2. B: ECG in sinus rhythm showing the same reverse polarity in leads I and aVL. C: Retrograde atrial activation sequence during right ventricular apical pacing showing eccentric activation with earliest atrial signals in CS 1–2. D: Nonsustained AV reentrant tachycardia with eccentric activation (earliest A in distal CS). Also, note late ventricular activation in the His channel relative to the far-field ventricular signal in distal CS (sinus beat following the tachycardia termination).

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  Figure 2:. A: Activation mapping performed during atrial pacing from the proximal CS showing earliest signals in the AMC region and successful radiofrequency energy applications (red dots). His signals are also seen (yellow points). Note the earliest V signal in the map 1–2 catheter. B: Fluoroscopy in left anterior oblique projection showing the ablation catheter positioned in the AMC via the retrograde transaortic approach at the site of successful ablation of the AP. C: Radiofrequency ablation successfully eliminated the AP within 1.4 seconds.

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  Figure 3:. Final 12-lead ECG showing sinus rhythm without any evidence of the AP. Note the early repolarization pattern in the inferior leads.