case_images: PMC10755169_01
case_images: (A) Association between Purkinje triggered by premature ventricular contraction and ventricular fibrillation [arrows represent Purkinje spikes], mapping catheter in left ventricular (LV) septal position between the anterior and posterior fascicles], (B) earliest activation of premature ventricular contraction on 3D mapping system, (C) anatomical correlation between earliest activation and Purkinje network system, (D) 12-lead electrocardiogram showing Purkinje potential preceding (-104 ms) the target premature ventricular contraction on ablation catheter (arrow), (E) voltage map of the left ventricle with septal substrate and mark out of both anterior and posterior fascicles (yellow dots) and earliest activation (square), (F) anatomical correlation of septal substrate and purkinje network system, (G) ablation of earliest activation and substrate modification (red dots), (H) anatomical reflect of substrate modification on Purkinje network system (Purkinje de-networking). AF, anterior fascicle of LBB; AV, aortic valve; Cx, circumflex artery; LAD, left anterior descending artery; LBB, left bundle branch; LV, left ventricle; PF, posterior fascicle.
case_images: ytad610f1.jpg
case_images: PMC10755169_01_ytad610f1.jpg
case_images: ytad610-F1
case_images: One day later, the patient experienced ventricular fibrillation (VF) storm that was triggered by premature ventricular contraction (PVC) (Figure 1A). An endocardial bipolar voltage map was performed which showed scarred tissue in the septal area affecting the conduction system and Purkinje network (Figure 1E and F). The earliest myocardial activation during PVCs was observed along the Purkinje network of the left bundle branch, too Figure 1B  and  C. This activation was consistently preceded by Purkinje potentials, which were followed by a PVC with the initiation of VF (Figure 1D). Afterward, ischaemic LV scar was targeted in terms of substrate modification and Purkinje de-networking (Figure 1G and H).