Available online 14 January 2023

We present the use of CineECG in visualizing abnormal ventricular activation in a case of a complex conduction disorder. CineECG combines the standard 12‑lead surface ECG with a 3D anatomical model of the heart. It projects the location and direction of the average ventricular activation and recovery on the heart model over time. In this case, CineECG was able to visualize the different type of fascicular conduction in this progressive conduction block. This novel imaging technique was able to provide additional insight in this complex case, and might be of use in other complex ECG patterns.

CineECG uses the standard 12‑lead surface ECG and combines this information with a standardized 3D anatomical model of the heart. It projects the location and direction (but not the amplitude) of the average ventricular activation and recovery on the heart model over time. The CineECG temporal starting point is set mid-QRS, the spatial starting point is the center of mass of the ventricles of the 3D model. From there, the complete CineECG trajectory is calculated. The normal CineECG trajectory was defined by the input of 6.500 12‑lead ECG's which were labeled as “normal” in the Physionet PTB-XL ECG Database and is displayed in Fig. 1 [1]. When depolarization of the ventricles starts, the CineECG starts in the superior part of the ventricles, left of the septum. From there it moves towards the right ventricle, representing the transseptal vector, after which it continues towards the apex and then towards the basal lateral wall of the left ventricle.

It has previously been shown that CineECG was able to localize the electrical substrate in the right ventricular outflow tract in patients with Brugada syndrome. CineECG was also able to differentiate between a left bundle branch block, and complete and incomplete right bundle branch block (RBBB) [2,3]. CineECG has not yet been used to describe bifascicular blocks. Therefore, we used the 12‑lead ECG from a progressive conduction block to determine if CineECG was able to identify this abnormal ventricular activation sequence. This is a complex conduction disorder, which is not easily identified by the less experienced ECG reader. We hypothesize that the newly developed CineECG may be of help in complex cases like this, providing visualization of the abnormal cardiac electrical activation.

We present a case of a progressive conduction block. The complexity of this case is due to the two level AV-junctional conduction block, resulting in group beating bradycardia with the combination of a right bundle branch (RBB) and a left anterior fascicle (LAF) Wenckebach block combined with a Mobitz II block of the left posterior fascicle (LPF) [4,5]. Fig. 2 shows the corresponding ECG, which displays a sequence of five P waves: the second and fourth P wave are blocked proximally in the

We report the use of CineECG in a case of abnormal ventricular activation. Using only the 12‑lead ECG, CineECG was able to visualize the progressive conduction block.

To better illustrate and explain the abnormal CineECG trajectories of this case, representative examples of sole RBBB and sole LAFB are shown in Fig. 5 and Fig. 6. The CineECG of a representative example of a RBBB shows normal septal activation from left to right. The direction then changes to inferior, but predominantly moves

CineECG is able to provide a novel visualization of abnormal and complex ventricular activation patterns. The CineECG trajectory corresponds with the description in ref. [3] that the two conducted beats are a result of a different type of fascicular conduction. Even more, the second conducted beat (after the third P wave) clearly shows that the activation is initiated at a more posterior site of the left ventricular wall.

This work was supported by Eurostars (project ID 115220 | CineECGPlus) in collaboration with ECG Excellence (NL), Epiqure (GE) and IRCCS Policlinico San Donato Milanese (IT).

Iris van der Schaaf: Conceptualization, Formal analysis, Visualization, Writing – original draft. Manon Kloosterman: Conceptualization, Writing – original draft. Machteld J. Boonstra: Conceptualization, Writing – original draft. Peter M. van Dam: Conceptualization, Software, Supervision, Writing – review & editing. Anton P.M. Gorgels: Conceptualization, Supervision, Writing – review & editing.

Peter van Dam is an owner of ECG Excellence.

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© 2023 Published by Elsevier Inc.