Letter to the Editor Herzschr Elektrophys 2014 DOI 10.1007/s00399-014-0320-z © Springer-Verlag Berlin Heidelberg 2014
This is the response to the comment available at DOI 10.1007/s00399-014-0316-8
We thank the authors of the letter to the editor for their interest in our recently published article [1] as well as for their valuable comments. We agree with the opinion of Chiale et al., that a shift in the intrathoracic heart position (for instance, occurring in pregnant women) can alter not only the cardiac axis but also the precordial transition. As a consequence, this might lead to a concealment of electrocardiographic features of Brugada syndrome. Therefore, it seems conceivable to
Dirk Prochnau · Hans R. Figulla · Ralf Surber Department of Internal Medicine I, Friedrich Schiller University, Jena, Germany
Response to the letter regarding article “First clinical manifestation of Brugada syndrome during pregnancy” record V1 and V2 in the intercostal spaces above the standard position. However, this is recommended not only for pregnant women. The alternative placement in a superior intercostal space is useful in all patients with a high clinical suspicion of Brugada syndrome who did not show a spontaneous type-1 Brugada-type ECG pattern [2]. Regarding the differences in ECG no. 1 and ECG no. 3, we have to keep in mind that different ECG patterns can be observed at different time points in the same patient [3, 4]. Since the performance of an ajmaline challenge is not possible in pregnant pa-
tients, we would finally suggest to use the electrocardiographic criteria described recently by Chevallier et al. [5]. The authors used angle measurements of chest lead V2 to discriminate between incomplete right bundle branch block (RBBB) and the Brugada type-2 and -3 ECG patterns. Therefore, the measurement of two angles (α, the angle between a vertical line and the downslope of the r wave, and β, the angle between the upslope of the S wave and the downslope of the r wave) was conducted [5]. The authors found that in particular the mean β angle was significantly smaller in patients with an incomplete RBBB
Fig. 1 7 Measurements of angle α and β in chest lead V2 of a patient with a genuine incomplete RBBB (a) and of our patient with Brugada syndrome during pregnancy (b). The patient with the incomplete RBBB had smaller α and β angles in comparison with our patient with Brugada syndrome (15° and 27° vs. 62° and 71°, respectively). These findings are in agreement with the results of Chevallier et al. [5] Herzschrittmachertherapie + Elektrophysiologie X · 2014
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Letter to the Editor in comparison with patients with a positive ajmaline challenge. In this study, the optimal cut-off value of the mean β angle was 58°, yielding a positive predictive value of 73 % and a negative predictive value of 87 %. The α angle was slightly less sensitive [5]. . Fig. 1 shows the measurement of the above-described angles α and β in the ECG of our patient and an ECG from a patient with a genuine incomplete RBBB.
Corresponding address D. Prochnau MD Department of Internal Medicine I Friedrich Schiller University Erlanger Allee 101, 07747 Jena [email protected]
Compliance with ethical guidelines Conflict of interest. D. Prochnau, H. R. Figulla, and R. Surber state that there are no conflicts of interest. The manuscript does not include studies on humans or animals.
References 1. Prochnau D, Figulla HR, Surber R (2013) First clinical manifestation of Brugada syndrome during pregnancy. Herzschrittmacherther Elektrophysiol 24:194–196 2. Shimizu W, Matsuo K, Takagi M et al (2000) Body surface distribution and response to drugs of ST segment elevation in Brugada syndrome: clinical implication of eighty-seven-lead body surface potential mapping and its application to twelve-lead electrocardiograms. J Cardiovasc Electrophysiol 11:396–404 3. Wilde AA, Antzelevitch C, Borggrefe M et al (2002) Proposed diagnostic criteria for the Brugada syndrome. Eur Heart J 23:1648–1654 4. Aizawa Y, Takatsuki S, Sano M et al (2013) Brugada syndrome behind complete right bundle-branch block. Circulation 128:1048–1054 5. Chevallier S, Forclaz A, Tenkorang J et al (2011) New electrocardiographic criteria for discriminating between Brugada types 2 and 3 patterns and incomplete right bundle branch block. J Am Coll Cardiol 58:2290–2298
2 | Herzschrittmachertherapie + Elektrophysiologie X · 2014
This is the response to the comment available at DOI 10.1007/s00399-014-0316-8
We thank the authors of the letter to the editor for their interest in our recently published article [1] as well as for their valuable comments. We agree with the opinion of Chiale et al., that a shift in the intrathoracic heart position (for instance, occurring in pregnant women) can alter not only the cardiac axis but also the precordial transition. As a consequence, this might lead to a concealment of electrocardiographic features of Brugada syndrome. Therefore, it seems conceivable to
Dirk Prochnau · Hans R. Figulla · Ralf Surber Department of Internal Medicine I, Friedrich Schiller University, Jena, Germany
Response to the letter regarding article “First clinical manifestation of Brugada syndrome during pregnancy” record V1 and V2 in the intercostal spaces above the standard position. However, this is recommended not only for pregnant women. The alternative placement in a superior intercostal space is useful in all patients with a high clinical suspicion of Brugada syndrome who did not show a spontaneous type-1 Brugada-type ECG pattern [2]. Regarding the differences in ECG no. 1 and ECG no. 3, we have to keep in mind that different ECG patterns can be observed at different time points in the same patient [3, 4]. Since the performance of an ajmaline challenge is not possible in pregnant pa-
tients, we would finally suggest to use the electrocardiographic criteria described recently by Chevallier et al. [5]. The authors used angle measurements of chest lead V2 to discriminate between incomplete right bundle branch block (RBBB) and the Brugada type-2 and -3 ECG patterns. Therefore, the measurement of two angles (α, the angle between a vertical line and the downslope of the r wave, and β, the angle between the upslope of the S wave and the downslope of the r wave) was conducted [5]. The authors found that in particular the mean β angle was significantly smaller in patients with an incomplete RBBB
Fig. 1 7 Measurements of angle α and β in chest lead V2 of a patient with a genuine incomplete RBBB (a) and of our patient with Brugada syndrome during pregnancy (b). The patient with the incomplete RBBB had smaller α and β angles in comparison with our patient with Brugada syndrome (15° and 27° vs. 62° and 71°, respectively). These findings are in agreement with the results of Chevallier et al. [5] Herzschrittmachertherapie + Elektrophysiologie X · 2014
| 1
Letter to the Editor in comparison with patients with a positive ajmaline challenge. In this study, the optimal cut-off value of the mean β angle was 58°, yielding a positive predictive value of 73 % and a negative predictive value of 87 %. The α angle was slightly less sensitive [5]. . Fig. 1 shows the measurement of the above-described angles α and β in the ECG of our patient and an ECG from a patient with a genuine incomplete RBBB.
Corresponding address D. Prochnau MD Department of Internal Medicine I Friedrich Schiller University Erlanger Allee 101, 07747 Jena [email protected]
Compliance with ethical guidelines Conflict of interest. D. Prochnau, H. R. Figulla, and R. Surber state that there are no conflicts of interest. The manuscript does not include studies on humans or animals.
References 1. Prochnau D, Figulla HR, Surber R (2013) First clinical manifestation of Brugada syndrome during pregnancy. Herzschrittmacherther Elektrophysiol 24:194–196 2. Shimizu W, Matsuo K, Takagi M et al (2000) Body surface distribution and response to drugs of ST segment elevation in Brugada syndrome: clinical implication of eighty-seven-lead body surface potential mapping and its application to twelve-lead electrocardiograms. J Cardiovasc Electrophysiol 11:396–404 3. Wilde AA, Antzelevitch C, Borggrefe M et al (2002) Proposed diagnostic criteria for the Brugada syndrome. Eur Heart J 23:1648–1654 4. Aizawa Y, Takatsuki S, Sano M et al (2013) Brugada syndrome behind complete right bundle-branch block. Circulation 128:1048–1054 5. Chevallier S, Forclaz A, Tenkorang J et al (2011) New electrocardiographic criteria for discriminating between Brugada types 2 and 3 patterns and incomplete right bundle branch block. J Am Coll Cardiol 58:2290–2298
2 | Herzschrittmachertherapie + Elektrophysiologie X · 2014
