Alternating anterior and posterior fascicular block and left septal fascicular block

Electrocardiogram of a patient affected by hypertensive cardiomyopathy showed an anterior fascicular block pattern and in right precordial leads an anterior displacement of QRS complex, characterised by a well evident jump of r wave from V1 to V2. Lead V2 showed qR morphology with embryonic q wave and very tall R wave. Septal q waves were not present in leads I and aVL. A subsequent electrocardiogram showed a posterior fascicular block pattern and the same findings in right precordial leads. Septal q waves were not present in inferior leads. Other causes of anterior displacement of QRS complex were ruled out by clinical/instrumental investigation. These findings are highly suggestive of left septal (middle) fascicular block coexisting with anterior and posterior fascicular block.