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  1. JÁNOS TOMCSÁNYI,
  2. JÓZSEF TENCZER
  1. National Korányi Institute
  2. Budapest, Hungary

http://dx.doi.org/10.1136/heart.83.5.582f

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    Editor,—We read with great interest the case study by Lau et al entitled “A new ECG sign of an accessory pathway in sinus rhythm: pseudo partial right bundle branch block”.1 However, ventricular pre-excitation can change any part of QRS; the sole terminal portion change is very rare.2 In the demonstrated case, the authors stated that the pseudo partial right bundle branch block was the only manifestation of the left sided accessory pathway. However, in the V3 leads, the PR seems to be shortened and the initial portion of QRS complexes can be interpreted as delta waves (fig 1).

    Figure 1
    Figure 1

    In lead V3, the arrows indicate the delta waves with short PR intervals.

    We think that the demonstrated case was not a post-excitation but a pre-excitation with discrete ECG signs.

    References

    1. ↵
      1. Lau EW,
      2. Ng GA,
      3. Griffith MJ
      (1999) A new ECG sign of an accessory pathway in sinus rhythm: pseudo partial right bundle branch block. Heart 82:244–245.
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Tenczer J,
      2. Littmann L,
      3. Fenyvesi T,
      4. et al.
      (1978) Procainamide induced unusual changes of the terminal QRS vectors in patients with and without pre-excitation. In Antalóczi Z, ed. Modern electrocardiology (Akadémia- Exerpta Medica, Amsterdam), p 493.

    This letter was shown to the authors who reply as follows:

    The pseudo partial right bundle branch block we propose is a subtle manifestation of left ventricularpre-excitation and notpost-excitation, even though the ECG feature occurs only in the terminal part of the QRS complex. The slight slurring in the upstroke of the QRS complex in V3 in the pre-ablation ECG alluded to by Tomcsányi and Tenczer was still present in the post-ablation ECG, proving that it was not part of the manifestation of ventricular pre-excitation.