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Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 174

When normal electrocardiogram is not normal?

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication1-Feb-2018

Correspondence Address:
Dr. Neeraj Parakh
Department of Cardiology, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_53_17

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How to cite this article:
Parakh N, Naik N, Juneja R. When normal electrocardiogram is not normal?. J Pract Cardiovasc Sci 2017;3:174

How to cite this URL:
Parakh N, Naik N, Juneja R. When normal electrocardiogram is not normal?. J Pract Cardiovasc Sci [serial online] 2017 [cited 2023 Jun 4];3:174. Available from: https://www.j-pcs.org/text.asp?2017/3/3/174/224487

Dear Editor,

A 26-year-old female presented with Ebstein's anomaly and recurrent palpitations. Her electrocardiogram (ECG) revealed a manifest accessory pathway (Panel A) [Figure 1]. Negative delta wave in lead V1 with negative delta waves in lead aVf localized this pathway to the right posteroseptal pathway as per Arruda's et al. criteria.[1] Electrophysiology study confirmed the pathway which was successfully ablated using radiofrequency energy. Ablation resulted in a normal looking ECG (Panel B) without any preexcitation, giving an impression of successful procedure. Intracardiac electrograms were also not suggestive of any preexcitation, with normal HV interval and no VA conduction. However, the absence of right bundle branch block (RBBB) in a patient with Ebstein's anomaly raised suspicion of the presence of another pathway. Incremental atrial pacing resulted in manifestation of Mahaim pathway (Panel C) with classical left bundle branch block pattern and superior QRS axis. Successful radiofrequency ablation of this Mahaim pathway resulted in complete RBBB pattern in ECG (Panel D), a classical finding of Ebstein's anomaly.
Figure 1: Electrocardiogram of the patient during ablation.

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The absence of RBBB in Ebstein's anomaly is very sensitive and specific marker of accessory pathway even if other markers of preexcitation (Short PR interval and delta wave) are absent.[2] Abnormal intra-atrial conduction and presence of long and slowly conducting pathways are two important reasons for normal PR interval in these patients. RBBB in Ebstein's anomaly is secondary to the developmental defects and is masked by the presence of right-sided accessory pathways. An orthodromic tachycardia or radiofrequency ablation of the accessory pathway will unmask the abnormal right bundle conduction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Arruda MS, McClelland JH, Wang X, Beckman KJ, Widman LE, Gonzalez MD, et al. Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-white syndrome. J Cardiovasc Electrophysiol 1998;9:2-12.  Back to cited text no. 1
Iturralde P, Nava S, Sálica G, Medeiros A, Márquez MF, Colin L, et al. Electrocardiographic characteristics of patients with Ebstein's anomaly before and after ablation of an accessory atrioventricular pathway. J Cardiovasc Electrophysiol 2006;17:1332-6.  Back to cited text no. 2


  [Figure 1]


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