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The electrophysiologic mechanism of ST-segment elevation in Brugada syndrome

Takashi Kurita, MD^*,*, Wataru Shimizu, MD^*, Masashi Inagaki, MD, Kazuhiro Suyama, MD^*, Atsushi Taguchi, MD^*, Kazuhiro Satomi, MD^*, Naohiko Aihara, MD^*, Shiro Kamakura, MD^*, Junjiro Kobayashi, MD and Yoshio Kosakai, MD

^* Division of Cardiology, National Cardiovascular Center, Suita, Osaka, Japan
Department of Cardiovascular Dynamics, National Cardiovascular Center, Suita, Osaka, Japan
Division of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

View larger version (59K): [in a new window]   Figure 1 Twelve-lead electrocardiogram (ECG) tracings in three patients with a Brugada-type ECG. All patients exhibited typical (coved-type) ST segment elevation and terminal T-wave inversion in the right precordial ECG leads (V1 and V2). An apparent right bundle branch block pattern and left axial deviation suggesting interventricular conduction delay are observed in Patients 1 and 2.

View larger version (23K): [in a new window]   Figure 2 (A) Simultaneous recording of endocardial and epicardial monophasic action potentials (MAPs) from the right ventricular outflow tract (RVOT) and electrocardiographic lead I during open chest surgery (tholacotomy implantable cardioverter defibrillator implantation) in Patient 1. In the epicardial MAP, an incomplete depolarization of phases 0 and 1, deep notch in phase 2 and delayed dome in phase 3 are observed. In contrast, a MAP obtained from an endocardial site of the RVOT exhibits a normal morphology. Because of the activation delay in the RVOT, a "notch" in the recording from the epicardium provokes a current flow from the endocardium to the epicardium at the end of QRS, which relates to J point (ST segment) elevation. The "dome" causes a rapidly attenuated or reversal transmural current, which results in a steep downslope of the ST-segment and T-wave inversion. The repolarization time in the epicardium was longer than those in the endocardium. (B) Epicardial MAPs recorded in a control patient during coronary artery bypass grafting. Despite detailed mapping around the epicardial sites of the RVOT, a "spike and dome" configuration was not observed in any of the patients. Endo = endocardial MAP; Epi = epicardial MAP; LAD = left anterior descending coronary artery; TV = tricuspid valve; star = pacing spike.