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Brugada electrocardiogram pattern and right bundle branch block !

Derek Crinion, Adrián Baranchuk "

EP Europace, euz020, https://doi.org/10.1093/europace/euz020

Published: 16 March 2019

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We read with great interest the recent case report by Eitel et al. entitled; ‘Postextrasystolic unmasking of Brugada electrocardiogram’. This case clearly exemplifies the
challenge of detecting Brugada pattern in the presence of right bundle branch block (RBBB). We wish to commend the author’s punctilious review of serial electrocardiograms
(ECG’s) to detect the Brugada Type 1 pattern that was revealed upon intermittent resolution of the RBBB. The diagnosis could have been easily overlooked. A patient
presenting with syncope in combination with RBBB, right axis deviation, and borderline PQ prolongation may well have underwent a pacemaker implant alone, and have
remained at risk of ventricular arrhythmias.

We wish to discuss and hopefully contribute to additional aspects of this case. Firstly, it should be emphasized that cardiac conduction disease and Brugada syndrome often
2 2
co-exist, as both conditions can be a manifestation of sodium channel dysfunction. Maury et al. demonstrated that RBBB was evident in 20% (29/143) of spontaneous Type 1
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Brugada pattern, and 33% (61/182) of those induced by sodium channel blocker challenge. The case by Eitel et al. mention a manoeuvre to overcome the masking effect of
RBBB. The right ventricular apex is paced at such an A-V interval to fuse ventricular activation, nullifying the effect of the RBBB delay that would have obscured the Brugada
pattern. We wish to highlight that the first to perform this was in fact Pablo A. Chiale in 2012, as part of his work at the Rosenbaum School of Electrocardiology in Buenos
3 4
Aires. This technique has been referred to as the Chiale manoeuvre. He has since passed and we wish to reference and acknowledge this pioneering work.

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In addition, Chiale’s detailed analysis of the ECG in Brugada syndrome when combined with RBBB is applicable and warrants further discussion. In RBBB, the ST-T wave in
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the early precordial leads is negative, being opposed to the main direction of the QRS electrical forces. The ST segment in the case by Eitel et al. was atypical as it exhibited a
3
degree of elevation, best appreciated in lead V1. A similar finding was also evident in Chiale’s index description, and should alert suspicion of Brugada syndrome. However, it
3 5
should be noted that Brugada pattern can be completely obscured in higher degree RBBB and contrary to this case report; Baranchuk et al. have previously described
normalization of Brugada pattern post extra-systolic pauses. Such is the dynamic and complex nature of the ECG changes associated with Brugada syndrome. As a result,
patients with persistent RBBB and a suspicion of Brugada syndrome should be referred to the electrophysiology lab to undergo the Chiale manoeuvre. The case report by Eitel
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et al. promotes awareness of this practice and also the additional benefit of backup ventricular pacing should a sodium channel blocker challenge be required.

Conflict of interest: none declared.

References

1 Eitel C, Eitel I, Tilz RR. Postextrasystolic unmasking of Brugada electrocardiogram. Europace  2019;21:32.
Google Scholar Crossref PubMed  

2 Maury P, Rollin A, Sacher F, Gourraud J-B, Raczka F, Pasquié J-L et al.  Prevalence and prognostic role of various conduction disturbances in patients with Brugada syndrome. Am J
Cardiol  2013;112:1384–9.
Google Scholar Crossref PubMed  

3 Chiale PA, Garro HA, Fernandez PA, Elizari MV. High-degree right bundle branch block obscuring the diagnosis of Brugada electrocardiographic pattern. Heart Rhythm  2012;9:974–6.
Google Scholar Crossref PubMed  

4 Aizawa Y, Takatsuki S, Sano M, Kimura T, Nishiyama N, Fukumoto K et al.  Brugada syndrome behind complete right bundle-branch block. Circulation  2014;129:e465.

5 Baranchuk A, Sicouri S, Elizari MV, Chiale PA. Pause-dependent normalization of ST-segment elevation during the ajmaline test in a patient with Brugada syndrome. Heart Rhythm 
2014;11:707–9.
Google Scholar Crossref PubMed  

Issue Section: Letter to the Editor

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.

This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus
/standard_publication_model)

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