Transient J-Wave Appearance in the Inferior-Lateral Leads during Electrical Storm in a Patient with Brugada Syndrome
A 67-year-old man presented to the emergency room of our hospital at midnight after resuscitated cardiac arrest which was witnessed. He had no relevant past medical history except for gastroesophageal reflux disease. He had fallen asleep at approximately 11:30 p.m., but at 11:39 p.m. his wife noticed that he had fallen into sudden apnea and stiffness. His son called 119 (emergency medical service) and performed cardiopulmonary resuscitation for 3 minutes before the emergency teams arrived. On arrival at our emergency room he appeared to be acutely ill-looking, and his mental state was alert. His vital signs were as follows: blood pressure 93/70 mm Hg, pulse rate of 112 bpm, body temperature 36.0℃. Laboratory results including complete blood count, biochemistry profile, electrolyte panels, cardiac enzymes ware within normal limits. The chest radiograph was also normal. While the patient was rushed to our hospital by ambulance, VF occurred 3 times. He was defibrillated with Automated External Defibrillator but VF occurred repeatedly. As he continued to develop VF, he was defibrillated 30 times until 9 a.m. (). The 12-lead ECG, initially recorded in the emergency room, revealed normal sinus rhythm with a heart rate of 93 bpm. There was coved type-ST elevation in V 1-2 and J-wave in II, III, aVF, V 5-6 leads (). Based on his family history, we found that his elder brother died in his sleep, when he was in his thirties. Furthermore, considering spontaneous presence of Brugada ECG patterns in the right precordial leads during the electrical stimulation (), we diagnosed him to have Brugada syndrome. Myocardial infarction was ruled out by coronary angiography with negative results of ergonovine test. We have no results of IC challenge test because we had no drug (e.g., flecainide) for the test, and we concluded that IC challenge test was not necessary because the patient had a typical pattern of Brugada syndrome on ECG. The Implantable Cardioverter Defibrillator was implanted for secondary prevention. Interestingly, abnormal low-amplitude terminal QRS deflection (J-wave), which was present in the inferior-lateral leads during VF storm () disappeared when his status became stable, without any VF recurrence (). An ECG taken five years ago showed normal sinus rhythm and no J-wave on the inferior-lateral leads and no Brugada pattern ECG on the right precordial leads ().