Local activation delay exacerbates local J-ST elevation in the epicardium: Electrophysiological substrate in Brugada syndrome Naoya Kataoka, MD, PhD,

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HeartRhythm Case Reports

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Local activation delay exacerbates local J-ST elevation in the epicardium: Electrophysiological substrate in Brugada syndrome Naoya Kataoka, MD, PhD, Satoshi Nagase, MD, PhD, Tsukasa Kamakura, MD, PhD, Takashi Noda, MD, PhD, Takeshi Aiba, MD, PhD, Kengo Kusano, MD, PhD, FHRS HeartRhythm Case Reports Volume 3, Issue 12, Pages 595-598 (December 2017) DOI: 10.1016/j.hrcr.2017.10.005 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 The relationship of unipolar ST elevation type with the bipolar voltage map (A) and the local activation time (LAT) map (B) and surface electrocardiogram (ECG) (C) before the administration of pilsicainide. A: The unipolar electrogram reveals saddleback-type ST elevation in the middle level of the right ventricular outflow tract (RVOT) and coved-type ST elevation in the high level of the RVOT. There is no obvious relationship between ST elevation type and bipolar voltage. Representative bipolar and unipolar electrograms are shown in each of the ST elevation types. B: ST elevation type clearly relates to prolonged LAT in the RVOT. C: Surface ECG on the standard position and V1 and V2 on the third and second intercostal spaces (3ics and 2ics, respectively) before pilsicainide administration. No–ST elevation type is shown as a green tag, saddleback-type is shown as a yellow tag, and coved-type is shown as a pink tag in panels A and B. LAD = left anterior descending artery; TA = tricuspid annulus. HeartRhythm Case Reports 2017 3, 595-598DOI: (10.1016/j.hrcr.2017.10.005) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 The relationship of unipolar ST elevation type with the bipolar voltage map (A) and the local activation time (LAT) map (B) and surface electrocardiogram (ECG) (C) after the administration of pilsicainide. A: The unipolar electrogram shows both saddleback-type and convex-type ST elevation in the middle level of the right ventricular outflow tract (RVOT), coved-type ST elevation in the tricuspid annulus, and convex-type ST elevation in the high level of the RVOT. Representative bipolar and unipolar electrograms are shown for each of the ST elevation types. B: The prolonged LAT zone in the low-voltage area of ≤0.5 mV (shown in A) shows coved- or convex-type ST elevation. C: Surface ECG after pilsicainide administration. Convex-type is shown as a red tag. Other colored dots are the same as those described in Figure 1. HeartRhythm Case Reports 2017 3, 595-598DOI: (10.1016/j.hrcr.2017.10.005) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 The relationship between local activation time (LAT) and local unipolar ST elevation at the timing of J point (J-ST) and 40 ms after J-point (J40-ST) in lead V5. A: Before the administration of pilsicainide. LAT is positively correlated with J-ST, the regression line y = 0.02x − 1.26, r = 0.84, P < .01, and n = 50. B: Before the administration of pilsicainide. J40-ST is also positively correlated with LAT, the regression line y = 0.01x − 0.48, r = 0.77, P < .01, and n = 50. C: After the administration of pilsicainide. LAT is positively correlated with J-ST, the regression line y = 0.01x − 0.25, r = 0.50, P < .01, and n = 40. D: After the administration of pilsicainide. J40-ST has no relationship with LAT, n = 40. Colored dots are the same as those described in Figures 1 and 2. HeartRhythm Case Reports 2017 3, 595-598DOI: (10.1016/j.hrcr.2017.10.005) Copyright © 2017 Heart Rhythm Society Terms and Conditions