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Vol. 73. Issue 10.
Pages 848 (October 2020)
ECG Contest
DOI: 10.1016/j.rec.2020.01.019
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Response to ECG, September 2020
Respuesta al ECG de septiembre de 2020
Kinán Rajjoub Al-Mahdia,
Corresponding author

Corresponding author:
, Juan Diego Sánchez Vegab, Ez Alddin Rajjoub Al-Mahdib
a Pabellón Docente, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
b Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Rev Esp Cardiol. 2020;73:76710.1016/j.rec.2020.01.018
Kinán Rajjoub Al-Mahdi, Juan Diego Sánchez Vega, Ez Alddin Rajjoub Al-Mahdi
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Figures (2)
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The ECG before the procedure shows advanced right bundle branch block and negative T waves in leads aVF and III.

Figure 1 shows first-degree atrioventricular block and QRS of 120ms with anterior-superior fascicular block and prominent anterior QRS forces (PAF), ST-T depression (upward arrows), and ST-T elevation in aVR (downward arrows), and repolarization changes resulting from the ischemia.

Figure 1

The differential diagnosis for PAF includes pre-excitation via a left lateral accessory pathway (option 2 incorrect, long PR), inferolateral infarction (option 3 incorrect, diffuse changes in repolarization point to left coronary artery or multivessel disease), right ventricular growth, and left septal fascicular block (LSFB).1 Acute pulmonary embolism, unlike chronic pulmonary hypertension, does not present with a monophasic R wave in the right precordial leads (option 1, incorrect).

The transient nature of PAF, along with the clinical context and presence of LSFB criteria (figure 2),2 supported the final diagnosis (option 4, correct). LSFB develops mainly due to proximal obstruction of the left anterior descending artery, before the first septal perforating branch.

Figure 2
A. Bayés de Luna, A. Riera, A. Baranchuk, et al.
Electrocardiographic manifestation of the middle fibers/septal fascicle block: a consensus report.
J Electrocardiol., 45 (2012), pp. 454-460
A. Pérez-Riera, R. Barbosa-Barros, A. Baranchuk.
Left septal fascicular block: characterization, differential diagnosis and clinical significance.
1.a ed., Springer Publishing Company, (2016), pp. 35-40
Revista Española de Cardiología (English Edition)

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