[CRT-FORUM] 52E 4 years old girl, with a Dilated Cardiomiopathy. Dr. Perez Riera

[CRT-INFO]

Dear Dr Pedro de la Paz
ECG ANALYSIS
1) Very short PRi interval: < 90 ms in children since the onset of P up 
to the onset of QRS. It represents the time the stimulus takes to go 
from the SA node until reaching the ventricles: 120 ms to 200 ms in 
adult. In children between 3 to 8yo the normal average of PR interval is 
130ms (0.13 s) Maximal normal limit 160 ms for rates between 80 and 120 
bpm.

2) Wider QRS complex: ?100 ms

3) Thickening or notch at the onset of QRS complex: DELTA wave 
duration=30mm.

4) Unaltered P-J interval (distance between P wave onset until J point) 
(normal value = 180 to 260 ms.)

5) Unaltered P-Z interval (distance between P wave onset until R apex.) 
Normal value = 150 to 230 ms.

6) Secondary alterations of ventricular repolarization (ST-T): depending 
on aberrant depolarization.

7) Type B WPW of Rosembaum classification: anomalous pathway between the 
right atrium and right ventricle (Galhanger points 3, 2 or 4: right 
lateral or right anterior), similar QRS pattern to LBBB, negative QRS 
predominance in right precordial leads leads and pure R waves in left 
leads I, VL, V5-V6.

8) Anomalous pathway located on Lindsay's IV region: negative delta wave 
in VR, SÂQRS not shifted (inferior QRS axis) transition zone in V3 on 
precordial leads. Ventricular activation in the horizontal plane of 
right lateral pre-excitation.

9) Anomalous pathway on Gallagher's point 3.

10) WPW Type I of European classification

11) Frequent premature atrial contractions

Management Proposal:
1) Genetic testing in proband and familial screening
2) RFCA: Radiofrequency Catheter Ablation because LBBB similar pattern: 
elimination of dessicronization, and easy approach
3) Pharmacological approach for CHF
4) Clinical observation for a few times.

Resynchronization is not necessary.

All the best for all
Andrés Ricardo Pérez Riera.MD
Chief of electrovectorcardiographic sector. ABC’s Medical School, ABC 
Foundation, Santo André, São Paulo, Brazil Riera at uol.com.br
> DEAR COLLEGUES OF THE CRT SYMPOSIUM , I AM SORRY FOR BEING ABSENT FOR 
> TWO DAYS BECAUSE OF PERSONALS REASONS , BUT I AM BACK AGAIN . I THINK 
> THAT WE HAVE ACHIEVED A VERY INTERESTING DISCUSSION OF THE CASE OF THE 
> 4 YEARS OLD GIRL WITH A COMPLEX SITUATION WHICH COMBINES DILATED 
> CARDIOMYOPATHY , WPW SYNDROME AND A SYNUS RYTHM DISORDER . WELL , I 
> COULD OBTAIN THE WHOLE ELECTROCARDIOGRAM , SCANNET IT AND NOW I SEND 
> IT TO YOU*** . EVERYTHING HAS BEEN POINTED OUT , BUT AFTER THIS , I M 
> SURE YOU WILL HAVE MANY ELEMENTS TO DEFINETELY HELP ME TO CHOOSE WHAT 
> IT SHOULD BE THE BEST APPROCH IN THIS CASE , THANKS A LOT TO ALL OF 
> YOU AND THE SYMPOSIUM ORGANIZERS FOR GIVE ME THE OPPORTUNITY TO SHARE 
> YOUR EXPERIENCES AND KNOWLEDGES , DR PEDRO DE LA PAZ
> ***


-- 
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee