IntroductionBrugada syndrome (BS), fi rst described in 1992, 1 is a major cause of sudden cardiac death (SCD), 2 syncope and ventricular tachyarrhythmia in young people with no structural heart disease.1 About 5% of survivors of cardiac arrest have no clinically identifi ed cardiac abnormality. About half of such cases are thought to be due to BS. 3The syndrome should be suspected in patients with documented idiopathic ventricular fi brillation, self-terminating polymorphic ventricular tachycardia, a family history of sudden cardiac death in a young person and/or syncope with the characteristic electrocardiography (ECG) changes. BS is usually diagnosed in adulthood, with an incidence of 0.05-0.60% in adults, and is very rarely diagnosed in children; the average patient age at diagnosis was 41 years in two large studies.5 The Brugada pattern is much more common in men with a ratio of 9:1 in one study; 6 men had a higher rate of syncope and sudden cardiac death in a large prospective registry study. 7 The syndrome characterised by right bundle branch block (RBBB) with ST elevation in leads V1 to V3 on electrocardiogram can transiently normalise for a period of time, making it diffi cult to diagnose. 8 ABSTRACTWe report two cases here, one presenting with atrial fi brillation who developed ventricular fi brillation after being treated with fl ecainide, unmasking the Brugada ECG pattern, and the other admitted with a history of collapse. These cases are followed by a comprehensive review of the published literature. Case 1A 25-year-old man was admitted to the accident and emergency (A&E) department with a history of collapse. There was no signifi cant previous history. His blood pressure was 129/65 mmHg and pulse was 160 beats per minute. Otherwise, examination was unremarkable.An ECG showed atrial fi brillation (Fig 1a). Metoprolol 5 mg intravenous (IV) bolus had no effect. He was then given fl ecainide 150 mg over 30 minutes, but after 20 minutes of fl ecainide loading he became very pale and developed ventricular tachycardia leading to ventricular fi brillation (Fig 1b). One shock of 360 J resulted in return of spontaneous circulation (ROSC) and reversion to sinus rhythm. His repeat ECG showed RBBB with ST elevation in V1 to V2, suggesting Brugada syndrome Type 1 (Fig 1c). A repeat ECG after 3 hours proved to be normal without any feature of Brugada-type ECG pattern (Fig 1d). Case 2A 57-year-old male collapsed and lost consciousness while sitting at home. His ECG showed RBBB with ST elevation in V1-V3 (Fig 2). His investigations showed a haemoglobin level of 13.7 g/dl, white cell count 12 × 10 9 /l, C-reactive protein 35 mg/l, sodium 137 mmol/l, potassium 4.3 mmol/l, creatinine 141 μg/l and urea 7.2 mmol/l. His chest X-ray (CXR) revealed consolidation of the right base and he was treated for chest infection with antibiotics. His transthoracic echocardiogram revealed good left ventricular systolic function with no evidence of structural heart disease. He was referred to an electrophysiologist for further managemen...

Key Clinical MessageSplinting and mechanical disruption of the mitral valve apparatus is an important limitation of an endocardial left ventricular (LV) pacing lead. Further, long‐term data are required before this approach is more widely adopted.

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ResponseEditor -We read with great interest the letter from Gottschalk et al, and we would like to thank them for their interest in our review article. We are grateful to the authors for drawing our attention to the terminology 'Brugada phenocopy' (BrP) and their work on BrP. Riera et al 1 introduced the term 'Brugada phenocopy' to describe the Brugada pattern that can be linked to a preexisting and well-known condition. They chose this term based on a previous defi nition of phenocopy: 'an environmental condition that imitates (copies) one produced by a gene'. The authors described a classic Brugada-type 1 ECG pattern in a patient intoxicated with propofol. In this particular case, the environmental condition was the infusion of propofol that triggered this particular ECG manifestation.BrP are clinical entities that are etiologically distinct from true congenital BrS. BrP are defi ned by ECG patterns that are identical to BrS but are elicited by various clinical circumstances.There are few key features that helps in distinguishing between BrP and the true congenital BrS. 2 First, patients with BrP have a reversible underlying condition, such as adrenal insuffi ciency, hypokalemia or myocardial ischemia, that elicits or induces the Brugada ECG pattern. There is prompt normalisation of the ECG once this underlying condition is resolved. This is contrary to true congenital BrS where the ECG manifestations are unmasked by sodium channel blockers, vagotonic agents, febrile states and various metabolic conditions. Second, patients with BrP have a low clinical pretest probability of true congenital BrS, as opposed to a high clinical pretest probability in patients with true congenital BrS who have a documented personal history of cardiac arrest, non-vagal syncope or a family history of sudden cardiac death. 3 Third, patients with BrP have a negative provocative challenge with a sodium channel blocker, while those with true congenital BrS have a positive provocative challenge. 2 Gottschalk et al recently developed a morphological classifi cation system which divides BrP into type-1 and type-2 BrP according to the manifested ECG pattern. The type-1 BrP is identical to a coved or type-1 Brugada ECG pattern and the type-2 BrP is identical to a saddleback or type-2 Brugada ECG pattern. [4][5][6] These two categories include A, B, and C qualifi ers. Class A includes BrP that have met all mandatory diagnostic criteria, including negative provocative challenge with a sodium channel blocker. Class B includes highly suspected BrP; however, not all mandatory diagnostic criteria are complete. Class C includes highly suspected BrP; however, provocative testing is not justifi ed, such as in cases with recent surgical right ventricular outfl ow tract manipulation 7 or BrP secondary to inappropriate ECG high pass fi lters. 8 The systematic diagnostic criteria discussed needs to be applied for suspected cases of BrP. We agree with the authors that the term 'Brugada phenocopy' should be used to replace 'Brugada-like ECG pattern' in the...