Download Ventricular Precontracting Area in the Wolff- Parkinson

Ventricular Precontracting Area in the
Wolff - Parkinson -White Syndrome
Demonstration in Man
By G1ULio BANDIERA, M.D.,
AND
PIER FAUSTO ANTOGNETTI, M.D.
By means of the analytic method of roentgenkvmography of Cignolini, 11 typical cases of'
Wolff-Parkinson-White syndrome were studied. Comparison of the kymographic tracings
with the synchronously registered electrocardiogram demonstrated precocious contraction of
a limited ventricular area, situated in the left ventricle in the A type and in the right ventricle in the B type.
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fN THE Wolff-Parkinson-White syndrome
I (W-P-W) the recognized causes of the
pathognomonic electrocardiograhic slow wave
(the so-called delta wave) inserted between P
and R are premature excitation of a ventricular area and an exceptionally slow transmyocardial conduction of the impulse, before
it reaches the Purkinje network, and hence the
whole of the myocardium.1 It has been experimentally verified that such conduction
may occur in a peculiar way in a few limited
ventricular areas localized in the arterial cone
of the heart, and chiefly in the right or left
ventricular area adjacent to the anterior segment of the interventricular septum, close to
the base.2
According to some authors, activation may
originate in the septum; however, it diffuses
first to one ventricle and then to the other.
Following the conception of Rosenbaum et
al., it would diffuse firstly to the left ventricle in the so-called A type (positive QRS in
V1, Vu, V2) and to the right one in the B type
(negative QRS in V1, VE, V2) .
Since investigative procedures employed to
date (jugular phlebography, cardiac sphygmography, roentgenkymography, electrokymography, etc.) have yielded uncertain and
inconstant data on the mechanical effects of
the ventricular pre-excitation phenomenon,
a study employing Cignolini's analytic method of roentgenkymography4'5 was undertaken.
By this method it is possible to obtain detailed
graphs that reflect the movement of almost
Ti-
I
FIG. 1. Method of timing the duration of x-ray
emission (second line) and synchronizing it with the
electrocardiogram (first and third lines) and the
plhonocardiogram (fourth line). Time intervals, 0.02
second.
From Medical Clinic of the University, Genoa,
Italy.
2.2
Circulation, Volume XVII, February 1958
22(3 ANDI EllA~
226
=AND) AkNTr(-)(UNETTI
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FIG. 2i. Diagram of the normal Iroenitgeinkyniiographlic trlacinigs comlpairei1 w-ith the electrocardiogram
(11(1 TlimeOIIOcaiogra ii.
Ti lie intervals 0.02 second.
ev-e. p)oint of the (aldriovasetilar profile and
W s ('11101ollog)i( <allv copnbe
eoiuint<tblaxl tiloti
.It II .I\I1
l(1118(4l V x togel leu
Writd saV1(llro lollsly 2eg( figs. 1 t11(1 2) .
isi (l eleetro('ardioglltltls'
Al oteovel, Ilhe sitlglc venlitrieulai areas can be
oliservld(lirectly 11nd(1 itol inidirectly by mieansx
01' 111 miove'Cincts of the (ri(eat veseuls
ensedti
1,v t1i(111. This last initlhiod, thllougtelei1tsivelv
x
'if
is ohiviosly ineoril iZ(J( )v iiaitv ,oikets.
l(eet, iasnitillh as aiy grivell Venlttri('lllr areal
mnay (0o1tract premtaturely without eausinlg a
l)l'('SS1I1 (giadliei( t blih-1t (e1ioug11 to open1 the
s(e1militia <1valves. Th11is has l('('1 P)roved( experimentally by IPiinmetal et al. ;8 they stiil-
evle
vln
Fi. 3.3 Cse of W-P-W syndrome, A type. Xote
the position of the c point (hegininiig of the yeiltriciil:i coitractimi) in the Ihiglier section (a) anldl ill
]l )etihe lowelr section (1)) of the left veuitrile; 0
pi)1 otosi stoliec
gilillilig of tihe at nizlI (cOllt lalctioni; x
aae. Timne initerv als 0.(02 secoild.
ulate(d the epiecar dial or ell(1o(ard(lial surface
o)1 both veintr i(clhes ele(tri(cally aid produlced
1 lic \-P-W a)attr ll; a filmed record of the
VENTRICULAR PRECONTRACTINGO AREA
9Ai27
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FIG. 4. Another ease of W-P-W syndrome, A type.
FIG. 5. Another case of W-P-W syndrome, A type.
conttractioln of the heart showed that in
\T-P-Wy systoles the mechanical activity of the
Iieart was distinctive. Atrial contraction was
normal, but it was not followed by the normal
ogil ized: (1) p)remlature contraction of the
pause. On the contrary, ventric-ular activity
followed immediately and 4 phases
were rec-
electrically activated myocardial area followed by a dis(conitinutious diffusion of the contraction wave to the surrounding areas (no
)loO(1 ejection from the ventricle takes place
in this phase) ; (2) contraction of the remain-
'228
BANDIERA AND ANTOGNETTI
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FIG. 7. Another case of W-P-W syndrome, A type.
FIG. 6.
The same case as that in figure 5, after the
disappearance of the electrocardiographic abnormalities. The precontraction still persists.
ing ventricular myocardium, which occurred
rapidly, as in normal systoles; (3) diastolic
relaxation and protrusion of the precon-
tracted area, while the remaining ventricular
muscle was still contracted; (4) occurrence
of diastole.
ROENTGENKYMOGRAPHIC STUDIES
In a series of typical cases, detailed roewtgenkymographic tracings were performed.
Apart from variations in general morphology
corresponding to the different physical types
of the patients, a peculiar abnormality wlas
detected, which we believe to be almost pathognomonic of the syndrome (figs. 3-10).
This consisted of a very clearly premature
o*lset of the ventricular contraction (so-calle(l
point c) in the higher section of the left ventricle in the A type and of the right ventricle in the B type. The significance of this
finding was indicated by the fact that this c
point was earlier, by .04 to over .08 second,
than the corresponding one in the lower sections of the same ventricle (fig. 11). In con-
VENTRICULAR PRECONTRACTING AREA
2292'
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FIG. 9. Case Cf W-P-W syn(lromIe, B type; records
in the right anterior olblique position. Note a
)lre'lIttire coltractionI ill the higher section of the
takeii
right
ventricle.
hllis last, which is scarcely recoglnizal)le inl the
FIG. 8. The sanme case as that in figure 7, after the
lisappearance of tile electrocardiographic abnormalities.
trast, the c point of the lower ventricular
sections occurred about .03 second after the
onset of QRS, as occurs in normal beats.
In other words, it is clear that the lower
sections of the ventricles are not late in starting to contract. Contrariwise, the higher seetions beginl contracting much earlier, coinci(lent with the abnormal delta wave on the
electrocardiogram. In placing the point, it
should be kept in mind that the onset of systole, which is represented by the apex of the
angle composed by the diastolic and systolic
boundaries of the ventricular tracings, is
closely followed by the protosystolic wave s.
c
proximity of the cardiac apex, becomes more
evident toward the base, where it often makes
up the outer point of the whole tracing. It
may also be noted that s wave, Nwhi(h is not
the expression of a local contraction, but all
effect of the whole ventricular systole, is
rarely asynchronous in the diff(renit sectioiis
of the heart. Furthermore, the great vessels
widen in a normal chronologic se(lueii(e after
the ventricular contraction. The atrial waves
also are normal in morphology and cliroitology. Every other roentgeilkymiogrral)lii( conipollent is quite normal.
In some eases a kymog-ramii was record(e
after the electrocardiographic abnormalities
disappeared following iiitravcnions procaine
amide. In these tracings the precoontracttioii
was also clearly recorded (figys. 6, 8 and 10).
230
BANDIERA AND ANTOGNETTI
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FIG. 11. Relationship between electrocardiogram
and iroeijtgeiikymniogra aij of the ventricular lpreconit ec
tioii area. Time inters-als 41 Secollnd.
liimited area of thlie venitvieular mvoeardium
is definitely demonstrated also ini man. Thec
c Ifta wave is the expression of the slow pro-
FIG.
the
10.
The
same
case
as
thnat in figure 9, :after
electlocar(lioglaIplhic
preconlltlactionl still persists.
disappearance of the
malities. The
1)l1o0-
llow eve r,it was not alwa-s possible to demoinstrate the ventrieular l)reeontraction area iii
a ll ceases: this was possible in 8 of our 11
Cases. rlhis failure occurred beeause the area
was ex((eed(lilngly- small or was sitluate d in
poilits
scarlv
(
ontrollable by the kvmo-
graphic anialysiS, espeeially in the
W-P-W svnMd rome.
state(l,
tie
(change (in
o
)d)
,
(legree
sometimes
may
of
our (cases
even
I)
It
Moreover,
ISC
B
as
type of
already
l)reeontraetion
from .04 to .08
in the
may
see-
samile snjeet.
I s5ION
eoncluded that
thle
kynographie
traeiimgs clearly- (eouifirni the existence of a
"'precontraetion area, sitllatedl in the arterial cone of the left venitriele ini the W-P-W
syndrome A type, and of the right ventricle
fii the B type. It seems, accordingly, tlhait
the arrival of a )rematlnCe (ex(xitaitioii at a1
grecssioli of the impullse fr om the pre-excitated
area to the adjaeent ventricular mvyoeardium.
Despite the delay produeed bl) this phenlomenon, the excitation reaeh}s the whole ventrieular mnvoeardium earlier thaii the impulse
traveling along the Tawarian pathways (fig.
12). -When thie eleetro(cardiogram does not
show the typical albormalities of the syn(rollie, it may be assume(d that l)re-exeitat;oll a11(l pl-ecolltalfetioii still exist in a griveti
ventricular area, hilt the exeitation reaehes
thle remiaini ngx ventrieclar imyoeard iurn l)y
way of physiologic pathways and the imi)ulse
arising in the albnormal area is bloeked.
Iii summary, it is evident that in W-P-W
5vI1(lromlle there exist 2 p)athways, of ventrieuilai. exeitation. rTil(e anomalous pathway, of
anatonie Or sinllvy ftnie(.tionial nature, (eon(dliuts the impulse faster thau the normnal
one, so that the exeitation reaehes the venltri(les earlier., and partieularly an area loeated
near the base of the righlit or left ventricle.
While this area eontraets the excitation
passes
to the
reminingiiii veutricular myo-
eardium with a ('ertaill delay (delta wave),
buit alwvayNs faster, lhowe\-ver, than the normal
iiuls'.19 tr av elingir atlong the normal path-
VENTRICULAR PRECONTRACTING- AREA
231
SUTHxrARIo IN INTERLINGUA
Studios effectuate in patientes con syndrome de Wolff-Parkinisoni-White per medio
de roentgenokymographia analytic ha producite le prime demonstration del occurrentia in
humanos de un contraction precoce in Un area
restringite del ventriculo. Iste area es situate in le proximitate del base in le venitriculo
sinistre in typo A e in le ventriculo dextere
in typo B.
REFERENCES
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1. SE(GERS, MI., LEQUIME, J., AND
,DENOLIN, :I.
L'activation ventricula ire preceoce de certains
coeUrs hyperexitables. Etude de l'onde delta
de l'eleetroeardiogrammiiiie. Cardiologia 8: 113,
1944.
2. FRAU, G., AND -MAGGI, G. C.: La sindrome di
Wolff-Parkinson-Whiite. Reggio Emilin, A.
Recordati, 19.54.
-, F. F., IJECHT, II. H., WILSON,
3. ROSENBAUM
F. N., ANI) JOHNSTON-, F. 1).: The potential
variations of the thorax anld the esopha.gus in
anoniialous atrio-ventrieulai excitation (WolffParkinson-White syndrome). Ami. Heart J.
29: 281, 1945.
4. CIcNIoLINI, P.: Roentgenehliiniografia eardiaca
e reginografia. Bologna, Cappelli, 1934.
: Roentgen(ehiinografla analitica eardina a.
a.
Radiolo-ia Practica, 4, 19-52).
6. ANTOGGNETTI, P. F.. ANDBD NDIERA, G.: Roentgoelnehiiiog'rni~fla analitica cardiaea. Studio mnorfocronologico delle grafiche rilevabili nelle
FIG. 12. Diagram of the 2 atriovenitricular coadiiitction
p)athw\vays
tion
area).
in tbe W-P-W
syn(lroillne (.5:pi'ceointla;l('-
ayst.s, which, therefore, finds the ventricles
already in a refractory state.
When, either spontaneously or by means
of p)harinaeologie agenlts, the impulse arising
from the pre-excited area is blocked, the ventrieles are excited in the normal way: but
the ventricular precontraction still persists.
varie
proiezioni eon registrazione contemnpo-
ranea di elettro e fonocardiogrananiiiia. Arch.
M~aragliano 8: 1t219, 1953.
7. BAtN1)IERA, G., AN-D ANTO0GNETTI, P. F.: Rilievi
li r oentgenehiniiogralfia analitica nelle turbe
del ritino e della conduzione. Folia cardiol.
13: 293, 1954.
S. PRINZMETAL ', If., KENNAM ER, R., CORDAY1, E.,
OSBoRNE-, J. A., FIELDS, J., AND SMITH, L. A.:
.Accelerated conduction. The Wolf-ParkinsonWhite synldromiiei and related conditions. NXe
York, Grune .and Stratton, Inc., 1952.
SUAMMARY
Studies carried out in the Wolff-ParkinsonWhite syndrome by means of the analytic
roentgenikyvinography have shown for the
first time in man a precocious contraction of
a limited ventricular area, which is situated
in proximity of the base, in the left ventricle
in the A type and iii the right ventricle iii
the B type.
9.
Ventricular Precontracting Area in the Wolff-Parkinson-White Syndrome:
Demonstration in Man
GIULIO BANDIERA and PIER FAUSTO ANTOGNETTI
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Circulation. 1958;17:225-231
doi: 10.1161/01.CIR.17.2.225
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX
75231
Copyright © 1958 American Heart Association, Inc. All rights reserved.
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