Key result
Targeted RF ablation guided by reverse break pattern permanently eliminates posteroseptal accessory pathway conduction.
Why the study?
The surface ECG is the cornerstone for localizing accessory pathways in WPW syndrome before catheter ablation, and the reverse break pattern in the precordial leads is a uniquely rare and highly specific finding for posteroseptal pathways.
Case Report (n=1)
No
Answers are grounded in this paper and cite their sources.
The "reverse break" (or double transition) pattern in precordial ECG leads V1-V3 is a specific marker that reliably predicts a right posteroseptal accessory pathway in Wolff-Parkinson-White syndrome, facilitating targeted 3D mapping and successful radiofrequency catheter ablation.
Background: The surface electrocardiogram (ECG) remains the cornerstone for localizing accessory pathways (APs) in WolffParkinson-White (WPW) syndrome prior to catheter ablation. The "reverse break" (or double transition) pattern in the precordial leads is a uniquely rare and highly specific finding for posteroseptal pathways. Case Presentation: A 60-year-old female with no prior medical history presented with recurrent palpitations. Her baseline 12-lead ECG exhibited normal sinus rhythm with overt pre-excitation. Notably, the precordial leads demonstrated a distinct reverse break sign: a negative delta wave in V1, an abruptly prominent positive delta wave in V2, and a return to a negative delta wave in V3. Echocardiographic evaluation was unremarkable. Based on this specific ECG morphology, a right posteroseptal AP was suspected. An electrophysiological study utilizing 3D electroanatomical mapping (EnSite™ Precision) confirmed the earliest pre-excited ventricular activation at the right inferoposterobasal (posteroseptal) region. Subsequent targeted radiofrequency ablation was successful; the post-ablation ECG showed normal sinus rhythm and the complete disappearance of delta waves. Conclusion: The reverse break pattern is a reliable and easily identifiable surface ECG signature that strongly predicts a right posteroseptal AP. Early recognition of this morphological shift significantly aids electrophysiologists in pre-procedural planning and improves ablation efficiency in anatomically complex regions.
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Değirmenci et al. (2026) conducted a case report in Wolff-Parkinson-White syndrome with right posteroseptal accessory pathway (n=1). 3D electroanatomical mapping-guided radiofrequency catheter ablation was evaluated on Elimination of accessory pathway conduction and normalization of surface ECG. Targeted radiofrequency catheter ablation guided by the ECG reverse break pattern and 3D mapping achieved complete, permanent loss of right posteroseptal accessory pathway conduction in a 60-year-old female.
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