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HEART RHYTHM DISTURBANCES

The electrocardiogram during sinus rhythm and tachycardia in patients with Mahaim fibers

The importance of an "rS" pattern in lead III

Eduardo Back Sternick, MD^*,*, Carl Timmermans, MD, Eduardo Sosa, MD, Fernando E.S. Cruz, MD, FACC, Luz-Maria Rodriguez, MD, FACC, Márcio Fagundes, MD, Luiz M. Gerken, MD^* and Hein J.J. Wellens, MD, FACC

^* Biocor Instituto, Belo Horizonte, Brazil
University Hospital, Maastricht, Maastricht, The Netherlands
Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
Instituto Nacional de Cardiologia Laranjeiras, Ministério da Saúde, Rio de Janeiro, Brazil

Manuscript received April 12, 2004; revised manuscript received May 28, 2004, accepted July 14, 2004.

^* Reprint requests and correspondence: Dr. Eduardo Back Sternick, rua Correias 281/301, Belo Horizonte, Minas Gerais, 30315-340 Brazil (Email: eduardosternick{at}aol.com).

OBJECTIVES: The purpose of the study was to identify the electrocardiographic (ECG) characteristics of the Mahaim fiber.

BACKGROUND: Mahaim fibers are slowly conducting accessory pathways reaching into the right ventricle. They often play a role in tachycardias.

METHODS: We retrospectively analyzed 40 patients with Mahaim fibers. Five patients had associated Wolff-Parkinson-White syndrome and were excluded from the study. Two patients had a short atrioventricular decremental accessory pathwayand were also excluded. The remaining 33 patients had a tachycardia with anterograde conduction over a Mahaim fiber. Twenty were female. Their mean age was 24 ± 10 years.

RESULTS: The most common pattern of minimal preexcitation during sinus rhythm was an rS pattern in lead III. This was found in 20 patients. There was a match between the presence of rS in lead III during sinus rhythm and left axis deviation during tachycardia with anterograde conduction over the Mahaim fiber. After ablation, a different QRS pattern emerged in lead III, indicating the absence of conduction over the Mahaim fiber. To obtain information on the prevalence of an rS pattern in lead III in age-matched controls with palpitations and without structural heart disease, the 12-lead ECG of 200 young individuals were examined. An rS pattern in lead III was found in 6%.

CONCLUSIONS: A narrow QRS with an rS pattern in lead III during sinus rhythm in a patient with a history of palpitations should alert the physician to the possibility of a Mahaim fiber. During tachycardia, these patients typically show a left bundle branch block-like QRS complex with left axis deviation.

Abbreviations and Acronyms   AH = atrio-His interval   AV = atrioventricular   ECG = electrocardiogram   HV = His-ventricular interval   LBBB = left bundle branch block   RF = radiofrequency