Abstract
A 78 year old lady sought medical attention for palpitations with
documented regular wide complex tachycardia with a left bundle branch
block (figure [1](#fig-cap-0001)) as well as atrial fibrillation.
She presented for a catheter ablation for atrial fibrillation and
presumed CTI-dependent atrial flutter. As a part of the procedure, we
performed an electrophysiology study. We performed pacing manoeuvres to
evaluate for the presence of a concealed accessory pathway. She had an
underlying left bundle branch block observed in sinus rhythm. Results of
para-Hisian pacing maneuver are displayed in figure
[2](#fig-cap-0002) with intracardiac electrograms and corresponding
12-lead ECG. Para-Hisian pacing is performed at a constant pacing
interval through the distal electrode of the His bundle catheter. There
is a decapolar catheter in the coronary sinus with the proximal
electrode positioned at the Os. Here are some questions to consider:
There are 4 different paced morphologies observed. What does each one of
these represent? How can we interpret the findings of this maneuver?
What role does pre-existing left bundle branch block play in our
interpretation?