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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. Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 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 Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 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 Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 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 Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 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' Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 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 Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 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 Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 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 Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 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. Print ISSN: 0009-7322. 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