Wolff Parkinson White syndrome type B with His depolarization occurring after the QRS. Further evidence that WPW QRS is a fusion beat

His bundle electrograms were recorded in a patient with Wolff Parkinson White syndrome (type B) during atrial pacing studies and during the induction of premature atrial depolarization at varying coupling intervals. Early ventricular depolarization (preexcitation) occurred simultaneously with the His depolarization, suggesting that conduction occurred via both the Kent and the normal A V nodal His Purkinje pathway during sinus rhythm. Atrial pacing at increasing rates showed progressive advance of the His spike into the QRS and increasing duration of the delta wave until the appearance of broad bizarre QRS complexes with prolonged P J intervals, suggesting major, if not total, depolarization of the ventricle by the Kent pathway. PAD's induced at coupling intervals of 360, 330, and 300 msec caused progressive delay of the His bundle depolarization, with the His spike occurring after the QRS at S₁ H intervals of 230, 265 and 325 msec, respectively, and Q H intervals of 123, 160 and 220 msec, respectively. These findings suggest that during sinus rhythm the QRS was a fusion beat. With early premature atrial stimulation, conduction occurred solely via the Kent pathway, with conduction via the normal A V nodal pathway encountering increasing delay. The finding of His depolarization occurring after the QRS suggests retrograde myocardial His block, and may explain the absence of paroxysmal supraventricular tachycardias in this patient.