A Pre-excited Wide QRS Complex: is That all There is?: Difference between revisions

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[[Puzzle_2006_3_108 Answer|Answer]]
[[Puzzle_2006_3_108 Answer|Answer]]
[[Image:Puzzle_2006_3_108_fig2.jpg|Figure 2|thumb]]
The ECG shows sinus rhythm (90 beats/min). The
electrical axis is shifted to the right. The PQ interval is
short (100 ms) and the QRS width is wide (120 ms).
There is initial slurring of the QRS complex, which is
positive in leads II, III, aVF, V2 to V5 and negative in
leads I and aVL. This indicates an initial electrical force
away from the left lateral free wall and can only be
based on activation via a Kent bundle, located in the
left lateral free wall. However, the terminal portion of
the QRS complex is slurring as well. It is negative in
the left lateral leads (I, aVL, V6) and positive in lead aVR
indicating a terminal force in the upward right direction,
which is obviously not explained by the intial ventricular
activation via the left lateral accessory pathway. This
configuration is compatible with right ventricular delay
(i.e. right bundle branch block). The lack of a terminal
R in lead V1 might be due to a slightly lower placement
of this lead. Hence, ventricular activation is the result of
pre-excitation via a left lateral Kent bundle and AV nodal
conduction with a pre-existent right bundle branch
block. Figure 2 shows the ECG (standard calibration)
after RF ablation of the bypass which indeed was located
in the left lateral wall. The PQ interval is longer and the
initial activation is now normal. As already anticipated
from the above analysis, the terminal right ventricular
activation and the QRS width are compatible with coexistent
right bundle branch block.
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