Академический Документы
Профессиональный Документы
Культура Документы
Arrhythmia Rounds
Section Editor: George J. Klein, M.D.
Case Presentation
Discussion
Capulzini et al.
Arrhythmia Rounds
953
the 1st beat and 130 ms in the 2nd, 3rd, and 4th beats. The
PR interval shortens to 100 ms in the 5th beat.
The differential diagnosis of this ECG should include:
(1) late ventricular premature beats, and (2) intermittent and
variable degree of preexcitation.
Intermittent and variable degree of intraventricular aberrant conduction is excluded because of the shortening of the
PR interval associated to the wider QRS complexes.
The possibility of late ventricular premature beat cannot
be excluded from this tracing. A variable degree of fusion
between a normally conducted beat and a late ventricular
extrasystole can, indeed, result in this pattern.
A mechanism that certainly has to be considered is intermittent and variable ventricular preexcitation. The rS
Figure 3. Atriofascicular pathway potential (arrows) identified at the 9 oclock position on the tricuspid valve as seen from the left anterior oblique
projection.
954
Sporadic cases of left-sided anterograde decremental pathway have been reported.4,5 It should be stressed that in these
patients there is no classic delta wave. ECG signs of ventricular preexcitation may become evident only during antidromic
tachycardia. Because of the right-sided location of these pathways, preexcited QRS complexes demonstrate LBBB-like
morphology.
The surface ECG in the presence of an AF fiber has shown
minimal preexcitation in up to 30% of patients.6,7 Apart from
the absence of q waves in the left precordial leads, no specific QRS complex pattern has been described.8 In 2004,
Sternick et al.9 reanalyzed a large series of patients with
AF fibers. They found that the rS pattern in lead III on
many ECGs, considered as normal in previous studies, were
associated with AF APs. This minimal preexcitation was
found in 60% of the patients reexamined.9 In their study they
also noted variability of minimal preexcitation on the same
ECG in 2 patients. Variability in preexcitation is consistent
with different degrees of fusion due to conduction over both
the normal AV conduction system and a decremental AP.
Thus, this is exactly what we found in our ECG and suggested to us a diagnosis of an AF pathway considering the
association with the LBBB morphology during the clinical
tachycardia.
The patient underwent an EP study and pacing maneuvers during tachycardia confirmed the presence of an AF
fiber. An AF pathway potential (arrows, Fig. 3) was identified at the 9 oclock position on the tricuspid valve in the
left anterior oblique projection, and successful ablation was
performed. After 2 months of follow-up the patient is free