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ICAO Preliminary Unedited Version — October 2008 III-App. 1B-21
20. 48-year-old asymptomatic air traffic controller who had always demonstrated the
Wolff-Parkinson-White (WPW) pattern. There are delta-waves on the upward inscription of the R
waves in S1 aVL and V4 – V6. The delta vector is -30º and the R-wave positive in V1. This
implies a left anterior para-septal insertion of the accessory pathway. Initial issue of a medical
assessment is not possible in the presence of a history of atrioventricular reentrant tachycardia. In
the event of the demonstration of successful accessory pathway ablation, certification without
restriction is possible. If the WPW pattern alone is present, certification is possible following an
electrophysiological study demonstrating an antegrade effective refractory period of the pathway
>300 ms, an HV interval <70ms, a Δ-Δ interval during atrial fibrillation >300ms, no evidence of
multiple pathways, and no inducible AV re-entry tachycardia. Long-term asymptomatic
individuals with this pattern may be granted unrestricted medical assessment.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-22
21. 49-year-old normotensive airline pilot who had demonstrated this pattern of diffuse ST-T-wave
flattening/inversion for twenty-five years whilst flying on active service. Although he was
normotensive, the inter-ventricular septum was increased at 2.1 cm. It is thus likely that he is
expressing a gene for hypertrophic cardiomyopathy. The exercise electrocardiogram
“normalised” at a high workload, and there was no evidence of electrical instability on Holter
monitoring. Most cases of hypertrophic myopathy require a limitation to multi-crew operations
but an inter-ventricular septum diameter >2.5 cm, ventricular tachycardia on Holter monitoring, a
family history of sudden cardiac death (SCD) and/or a fall in the blood pressure on exercise are
all indicators of excess risk of incapacitation and must be considered incompatible with medical
certification.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-23
22. 50-year-old ATPL-holder with HCM1. A bradycardia, probably of left atrial origin, is present
with a heart rate of 57 bpm. In the hexaxial leads the T-waves are flat but otherwise
unremarkable. The “dome and dart” P-waves in V1 suggest a left atrial focus whilst the T-waves
are biphasic in V3 and V4 with late notching in V5. The pilot’s exercise performance is excellent
and no electrical instability is detected on repeated Holter monitoring. His medical assessment
was restricted to multi-crew operations.
1 HCM (hypertrophic cardiomyopathy) is a condition with protean ECG manifestations and the
condition should be borne in mind when confronted with a bizarre recording.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-24
23. 0-year-old PPL-holder who demonstrates a heart rate of 73 bpm. Although the pacing spikes are
not evident, a bipolar dual chamber pacemaker is present. The pacemaker had been inserted on
account of first degree atrioventricular block with a PR-interval of 400 ms, left axis deviation
(-60º) and QRS duration of 158 ms. Mobitz type I AV block was seen at night. Thallium MPI was
negative. As the pilot was not technically pacemaker dependent, a Class 2 medical assessment
was permitted.
ICAO Preliminary Unedited Version — October 2008 III-App. 1B-25
24. 38-year-old applicant for a class I medical assessment who demonstrates the characteristic
features of the Brugada pattern although he had always been asymptomatic. Specifically there is
an incomplete right bundle branch aberration with drift of the ST-segment away from the r’ rather
than a firm downward inscription. This is an example of an iron channelopathy, the sodium
encoding gene SCN5a being involved. An initial applicant should be refused medical certification
but new presentation in an existing licence-holder should be reviewed in the light of family
history and past history of any event consistent with syncope. Holter monitoring should search
for possible ventricular tachycardia (torsade de pointes). If these findings were present, medical
assessment should be denied. Minor variants overlapping with normal ones are common and
specialist input is needed.
— — — — — — — —
ICAO Preliminary Unedited Version — October 2008 III-App. 2-1
APPENDIX 2.— ILLUSTRATIVE EXERCISE ELECTROCARDIOGRAMS
25. 30-year-old ATPL-holder who underwent exercise electrocardiography for variable T-wave
flattening in the left chest leads of his resting electrocardiogram. He achieved 100% of his age
　
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本文鏈接地址：Manual of Civil Aviation Medicine 1(111)