Correlation between functional and ultrastructural substrate in Brugada syndrome Pablo E. Tauber, MD, Virginia Mansilla, MD, Guillermo Mercau, MD, Felix.

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Correlation between functional and ultrastructural substrate in Brugada syndrome Pablo E. Tauber, MD, Virginia Mansilla, MD, Guillermo Mercau, MD, Felix Albano, MD, Ricardo R. Corbalán, Sara S. Sánchez, PhD, Stella M. Honoré, PhD HeartRhythm Case Reports Volume 2, Issue 3, Pages 211-216 (May 2016) DOI: 10.1016/j.hrcr.2015.12.001 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 A: Twelve-lead electrocardiogram (ECG) tracings baseline: patent type 2 ECG (not diagnostic) displaying a PR interval of 200 milliseconds, QRS axis of 0°, QRS duration in V2 [fourth intercostal space (ICS)] of 120 milliseconds, QT/QTc of 360/383 milliseconds, the presence of an end-QRS slur with a descending ST segment in DI and horizontal in aVL, and saddleback-type ST-segment elevation observed in V2 (second ICS). Shift of right precordial leads in second higher ICSs does not reveal a type 1 patent ECG, but an increased saddleback-type ST-segment elevation is observed in V2. Note the presence of the end-QRS slur in DI and aVL, with a J-point peak ≥0.2 mV and descending ST segment in DI and horizontal in aVL (red arrows). B: Twelve-lead ECGs after oral administration of 400 mg of flecainide: In the third hour, the type 2 ECG is converted to the diagnostic type 1 patent ECG, which consists of a coved-type ST-segment elevation, observed in V2 of the standard 12-lead ECG (fourth ICS) and in V1, V2, and V3 recorded from the second ICS. Depolarization abnormalities are present as a prolonged PR interval of 210 milliseconds, QRS axis +8°, prolonged QRS duration in V2 of 150 milliseconds, and a high final R wave in aVR of 3 mm, consistent with right end conduction delay. Repolarization disorder can also be seen, with a prolonged QT/QTc interval of 420/481 milliseconds. Note the disappearance of the end-QRS slur in DI and aVL and the appearance of S waves and leveling ST segment (red arrows). HeartRhythm Case Reports 2016 2, 211-216DOI: (10.1016/j.hrcr.2015.12.001) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 A: Baseline AH interval of 110 milliseconds, HV-DI of 60 milliseconds, and HV-V2 of 40 milliseconds; QRS duration in DII of 90 milliseconds and QRS duration in V2 of 150 milliseconds, indicating slow conduction in the right ventricular outflow tract (RVOT). B: Note the presence of middiastolic electrograms (EGMs) during sinus rhythm (red arrows). We identified areas that contained low-amplitude late potentials, corresponding to the anterior area of the high RVOT on the voltage map, where a systolic low-voltage EGM can also be seen in the proximal ablator. C: Spontaneous ventricular tachycardia from the RVOT and diastolic EGMs preceding the onset of the QRS complex can be seen (red arrows), which correspond to presystolic Purkinje-type potentials of low amplitude and high frequency preceding the QRS for 20 or 30 milliseconds. D. Voltage and electroanatomical maps, and the 3 areas of different voltage. HV-DI = HV interval measured DI; HV-V2 = HV interval measured V2; RVOT-D = distal right ventricular outflow tract; RVOT-P = proximal right ventricular outflow tract. HeartRhythm Case Reports 2016 2, 211-216DOI: (10.1016/j.hrcr.2015.12.001) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 Endocardial biopsy by transmission electron microscopy. Voltage and electroanatomical map of A: normal lower area of the right ventricular outflow tract (voltage ≥ 1.5 mv), and B: Purkinje cell with abundant secretory vesicles in the normal lower area. Note that when approaching the pathological area, cytoplasmic disorganization, vacuolization (*) and myofibrillar remains in the adjacent cells were evident. C: Mitochondria showing normal crest, lipofuscin deposits near the myocyte nucleus and myofibrils with classic characteristics in normal lower area. D: Voltage and electroanatomical map of peripheral area (voltage between 0.5 and 1.5 mv). E: Myofibrillar and cellular remains in the peripheral area. F: Note the disappearance of the mitochondrial crests, mitochondrial swelling, and myofibrillar disorganization (*) in the same area. G: Voltage and electroanatomical map of central area (voltage ≤ 0.5 mv). Note the bioptome connected to the navigation system. H: Strong vacuolization and cell destruction in the central area. I: Intense cytoplasmic disorganization, vacuolization, and remains of myocardial fibers (*) in the central area. lp = lipofuscin deposits; mi = mitochondria; mf = myofibrils; nu = nucleus; pc = Purkinje cell. Scale bar: B 2.2 μm; C, F, I: 1.42 μm; E, H: 3.33 μm. HeartRhythm Case Reports 2016 2, 211-216DOI: (10.1016/j.hrcr.2015.12.001) Copyright © 2016 Heart Rhythm Society Terms and Conditions