Clin. Cardiol. 8, 51-56 (1985) 0 Clinical Cardiology Publishing Co., Inc. Wolff-Parkinson- White Syndrome Type B and Left Bundle-Branch Block: Electrophysiologic and Radionuclide Study P. RAKOVEC, M.D., D.Sc., F.C.C.P., I. KRANJEC, M.D., J. J. FETTICH, M.D., J. JAKOPIN, M.D., D.Sc., v. FIDLER, M.Sc., J. TURK, M.D., D.Sc. Centerof Cardiovascular Disease and Clinic of Nuclear Medicine, University Clinical Center, Ljubljana, Slovenia, Yugoslavia Summary: Coinciding left bundle-branch block and Wolff-Parkmson-Whitesyndrome type B, a very rare elec- trocardiographic occurrence, was found in a patient with dilated cadiomyopathy. Electrophysiologic study revealed eccentric retrograde atrial activation during ventricular pacing, suggesting right-sided accessory pathway. At pro- grammed atrial pacing, effective refractory period of the accessory pathway was 3 10 ms; at shorter pacing coupling intervals, normal atrioventricular conduction with left bundle-branch block was seen. Left bundle-branch block was seen also with His bundle pacing. Radionuclide phase imaging demonstrated right ventricular phase advance and left ventricular phase delay; both right and left ventricular phase images revealed broad phase distribution histo- grams. Combined electrophysiologic and radionuclide investigations are useful to disclose complex conduction abnormalities and their mechanical correlates. Key words: preexcitation, bundle-branch block, elec- trophysiology, phase image Introduction Bundle-branch block and preexcitation syndrome are considered to be independent conditions with different anatomic substrates (Denes et al., 1975; Pick and Fisch, Address for reprints: Peter Rakovec, M.D. Center of Cardiovascular Diseases ZaloSka 7, 61 105 Ljubljana Yugoslavia Received: April 7, 1984 Accepted: June 23, 1984 1958). Therefore, they occur together very rarely; the coexistence of ventricular preexcitation and left bundle- branch block seems to have even lower incidence than the combination of right bundle-branch block and preexcita- tion (Mendosa et al., 1980). In the present report, we describe (1) electrophysiologic findings and (2) radionuclide phase analysis of ventricular and atrial contraction in a case of Wolff-Parkinson-White (WPW) syndrome with a right-sided accessory pathway and left bundle-branch block. Methods The patient, a 71-year-old woman, was studied in a postabsorptive, nonsedated state. She gave informed con- sent for the study. All cardioactive medication was stop- ped at least five half-lives before the study. Two bipolar electrode catheters were passed percutaneously into the femoral vein and one hexapolar electrode catheter (type Berkovits-Castellanos, USCI) was passed by cutdown on the basilic vein at the elbow. One bipolar electrode catheter was advanced to lie across the tricuspid valve to record the His bundle electrogram. The distal pair of electrodes of the hexapolar catheter were used for right ventricular pacing, the two proximal pairs for high right atrial pac- ing and recording. The second bipolar electrode catheter was used for recording of low lateral right atrial elec- trograms or left atrial electrograms (via pulmonary artery). Stimuli of 1.8 ms duration and two times diastolic thres- hold were provided by a programmable electrical pulse generator (Medtronic 5325). All recordings were made on a direct ink-jet multichannel recorder (Mingograf Car- direx 6T Siemens). Electrocardiographicallygated radionuclide blood-pool imaging was performed in basal condition during atrial and ventricular pacing. Technetium-99m, 25 mCi were
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