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Ikeda S, Sakamoto K, Sugawara M, Yakabe D, Nagaoka K, Kowase S, Inoue S, Morishige K, Mukai Y, Tsutsui H, Kinugawa S. Paced QRS morphology mimicking complete left bundle branch block induced by right ventricular pacing is associated with pacing-induced cardiomyopathy. J Cardiovasc Electrophysiol 2024; 35:906-915. [PMID: 38433355 DOI: 10.1111/jce.16229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Right ventricular (RV) pacing sometimes causes left ventricular (LV) systolic dysfunction, also known as pacing-induced cardiomyopathy (PICM). However, the association between specifically paced QRS morphology and PICM development has not been elucidated. This study aimed to investigate the association between paced QRS mimicking a complete left bundle branch block (CLBBB) and PICM development. METHODS We retrospectively screened 2009 patients who underwent pacemaker implantation from 2010 to 2020 in seven institutions. Patients who received pacemakers for an advanced atrioventricular block or bradycardia with atrial fibrillation, baseline LV ejection fraction (LVEF) ≥ 50%, and echocardiogram recorded at least 6 months postimplantation were included. The paced QRS recorded immediately after implantation was analyzed. A CLBBB-like paced QRS was defined as meeting the CLBBB criteria of the American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society in 2009. PICM was defined as a ≥10% LVEF decrease, resulting in an LVEF of <50%. RESULTS Among the 270 patients analyzed, PICM was observed in 38. Baseline LVEF was lower in patients with PICM, and CLBBB-like paced QRS was frequently observed in PICM. Multivariate analysis revealed that low baseline LVEF (odds ratio [OR]: 0.93 per 1% increase, 95% confidence interval [CI]: 0.89-0.98, p = 0.006) and CLBBB-like paced QRS (OR: 2.69, 95% CI: 1.25-5.76, p = 0.011) were significantly associated with PICM development. CONCLUSION CLBBB-like paced QRS may be a novel risk factor for PICM. RV pacing, which causes CLBBB-like QRS morphology, may need to be avoided, and patients with CLBBB-like paced QRS should be followed-up carefully.
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Affiliation(s)
- Shota Ikeda
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
- Department of Cardiology, Yokohama Rosai Hospital, Kohoku-ku, Yokohama, Japan
| | - Kazuo Sakamoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Masafumi Sugawara
- Department of Cardiology, Yokohama Rosai Hospital, Kohoku-ku, Yokohama, Japan
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chuo-ku, Chiba, Japan
| | - Daisuke Yakabe
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
- Department of Cardiovascular Medicine, National Hospital Organization Kyushu Medical Center, Clinical Research Institute, Chuo-ku, Fukuoka, Japan
| | | | - Shinya Kowase
- Department of Cardiology, Yokohama Rosai Hospital, Kohoku-ku, Yokohama, Japan
| | - Shujiro Inoue
- Department of Cardiology, Aso Iizuka Hospital, Iizuka, Japan
| | - Kunio Morishige
- Department of Cardiology, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Yasushi Mukai
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
- Division of Cardiology, Fukuoka Red Cross Hospital, Minami-ku, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
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Li C, Wang N, Chang Q, Pan D. An interesting electrocardiogram caused by lead reversal. BMC Cardiovasc Disord 2024; 24:217. [PMID: 38643100 PMCID: PMC11031905 DOI: 10.1186/s12872-024-03875-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND During normal sinus rhythm, atrial depolarization is conducted from right atrium to left atrium through Bachmann's bundle, and a normal P wave axis which is measured on the frontal plane is between 0º and + 75º. The change of P wave polarity is helpful for the analysis of origin point. CASE PRESENTATION We report a patient with negative P wave in lead I. The characteristics of QRS complex in leads V1 to V6 are helpful to preliminarily differential diagnosis. The 12-lead electrocardiogram (ECG) with correct limb leads (right arm-left arm) placement shows sinus rhythm with complete right bundle branch block (RBBB). CONCLUSIONS The change of P wave polarity as well as characteristics of QRS complex can help identify limb-lead reversals.
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Affiliation(s)
- Changjun Li
- Department of Gerontology, The First Affiliated Hospital of Jinzhou Medical University, Renmin Street, Jinzhou, 121000, Liaoning Province, China
| | - Nan Wang
- Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, Renmin Street, Jinzhou, 121000, Liaoning Province, China
| | - Qinghua Chang
- Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, Renmin Street, Jinzhou, 121000, Liaoning Province, China
| | - Dianzhu Pan
- Department of Respiratory, The First Affiliated Hospital of Jinzhou Medical University, Renmin Street, Jinzhou, 121000, Liaoning Province, China.
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Barold SS, Herweg B. Centennial of the original description of Mobitz type II second-degree atrioventricular block. J Cardiovasc Electrophysiol 2024; 35:846-847. [PMID: 38348495 DOI: 10.1111/jce.16199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/21/2024] [Indexed: 04/10/2024]
Abstract
The year 2024 marks the centenary of Mobitz's description of type II second-degree atrioventricular block. Its definition remains valid to this day with only minor modification for the diagnosis of infranodal conduction block. Mobitz a century ago indicated that his type II atrioventricular block was associated with Stock-Adams attacks and a prolonged duration of the QRS complex before the eventual description of bundle branch block.
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Affiliation(s)
- S Serge Barold
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Bengt Herweg
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Ponnusamy SS, Vijayaraman P. Reply to the Editor- Alternate interpretation of left bundle branch potential. Heart Rhythm 2024; 21:505-506. [PMID: 38141901 DOI: 10.1016/j.hrthm.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 12/25/2023]
Affiliation(s)
| | - Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
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Ito R, Kondo Y, Nakano M, Kajiyama T, Nakano M, Kitagawa M, Sugawara M, Chiba T, Kobayashi Y. Interaction of left ventricular size with the outcome of cardiac resynchronization therapy in Japanese patients. Clin Cardiol 2024; 47:e24267. [PMID: 38619004 PMCID: PMC11017297 DOI: 10.1002/clc.24267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/08/2024] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND We analyzed the influence of the QRS duration (QRSd) to LV end-diastolic volume (LVEDV) ratio on cardiac resynchronization therapy (CRT) outcomes in heart failure patients classified as III/IV per the New York Heart Association (NYHA) and with small body size. HYPOTHESIS We proposed the hypothesis that the QRSd/LV size ratio is a better index of the CRT substrate. METHODS We enrolled 114 patients with advanced heart failure (NYHA class III/IV, and LV ejection fraction >35%) who received a CRT device, including those with left bundle branch block (LBBB) and QRSd ≥120 milliseconds (n = 60), non-LBBB and QRSd ≥150 milliseconds (n = 30) and non-LBBB and QRSd of 120-149 milliseconds (n = 24). RESULTS Over a mean follow-up period of 65 ± 58 months, the incidence of the primary endpoint, a composite of all-cause death and hospitalization for heart failure, showed no significant intergroup difference (43.3% vs. 50.0% vs. 37.5%, respectively, p = .72). Similarly, among 104 patients with QRSd/LVEDV ≥ 0.67 (n = 54) and QRSd/LVEDV < 0.67 (n = 52), no significant differences were observed in the incidence of the primary endpoint (35.1% vs. 51.9%, p = .49). Nevertheless, patients with QRSd/LVEDV ≥ 0.67 showed better survival than those with QRSd/LVEDV < 0.67 (14.8% vs. 34.6%, p = .0024). CONCLUSION Advanced HF patients with a higher QRSd/LVEDV ratio showed better survival in this small-body-size population. Thus, the risk is concentrated among those with a larger QRSd, and patients with a relatively smaller left ventricular size appeared to benefit from CRT.
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Affiliation(s)
- Ryo Ito
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Yusuke Kondo
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Masahiro Nakano
- Department of Advanced Cardiorhythm TherapeuticsChiba University Graduate School of MedicineChibaJapan
| | - Takatsugu Kajiyama
- Department of Advanced Cardiorhythm TherapeuticsChiba University Graduate School of MedicineChibaJapan
| | - Miyo Nakano
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Mari Kitagawa
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Masafumi Sugawara
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Toshinori Chiba
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Yoshio Kobayashi
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
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Pavri BB. To the Editor- Alternate interpretation of left bundle branch potential. Heart Rhythm 2024; 21:505. [PMID: 38142833 DOI: 10.1016/j.hrthm.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 12/26/2023]
Affiliation(s)
- Behzad B Pavri
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
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Kodama N, Nakagawa M, Ishii Y, Yufu K, Yamauchi S, Yamamoto E, Miyoshi M, Abe I, Kondo H, Fukui A, Satoh H, Akiyoshi K, Fukuda T, Shinohara T, Teshima Y, Takahashi N. R-R' interval in the left bundle branch block predicts long-term outcomes after cardiac resynchronization therapy by estimating greater mechanical dyssynchrony and viable myocardium. Heart Rhythm 2024; 21:436-444. [PMID: 38154602 DOI: 10.1016/j.hrthm.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Typical left bundle branch block (LBBB) shows 2 peaks of the R wave, which reflect activation reaching the interventricular septum (R) and posterolateral wall (R') sequentially. OBJECTIVE The purpose of this study was to investigate the relationship among R-R' interval (RR'), mechanical dyssynchrony, extent of viable myocardium, and long-term outcomes in cardiac resynchronization therapy (CRT) candidates. METHODS The study enrolled 49 patients (34 men; mean age: 69 ± 11 years) with LBBB who received CRT. The LBBB definition used requires the presence of mid-QRS notching in leads V1, V2, V5, V6, I, and aVL. Baseline evaluations were QRS duration (QRSd) and RR' measured from the 12-lead electrocardiogram; eyeball dyssynchrony (apical rocking and septal flash) and opposing-wall delay by speckle tracking from echocardiography, and extent of viable myocardium assessed by thallium-201 single-photon emission computed tomography. Primary outcomes included the combination of all-cause death and heart failure-related hospitalization. RESULTS RR' predicted volumetric response better than QRSd (area under the curve 0.73 vs 0.67, respectively). The long RR' group (≥48 ms) revealed more frequent eyeball dyssynchrony and significantly greater radial (SL) and circumferential dyssynchrony (AP and SL) and %viable segment than the short RR' group. In multivariate regression analysis, only RR' ≥48 ms was independently associated with higher event-free survival rates following CRT (hazard ratio 0.21; P = .014). CONCLUSION These findings suggest that RR' in complete LBBB was associated with mechanical dyssynchrony, extent of viable myocardium, and long-term outcomes following CRT.
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Affiliation(s)
- Nozomi Kodama
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Mikiko Nakagawa
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan.
| | - Yumi Ishii
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Kunio Yufu
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Syuichiro Yamauchi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Ena Yamamoto
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Miho Miyoshi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Ichitaro Abe
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Hidekazu Kondo
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Akira Fukui
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Hideki Satoh
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Kumiko Akiyoshi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Tomoko Fukuda
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Yasushi Teshima
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
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Leinveber P, Halamek J, Curila K, Prinzen F, Lipoldova J, Matejkova M, Smisek R, Plesinger F, Nagy A, Novak M, Viscor I, Vondra V, Jurak P. Ultra-high-frequency ECG volumetric and negative derivative epicardial ventricular electrical activation pattern. Sci Rep 2024; 14:5681. [PMID: 38454102 PMCID: PMC10920693 DOI: 10.1038/s41598-024-55789-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
From precordial ECG leads, the conventional determination of the negative derivative of the QRS complex (ND-ECG) assesses epicardial activation. Recently we showed that ultra-high-frequency electrocardiography (UHF-ECG) determines the activation of a larger volume of the ventricular wall. We aimed to combine these two methods to investigate the potential of volumetric and epicardial ventricular activation assessment and thereby determine the transmural activation sequence. We retrospectively analyzed 390 ECG records divided into three groups-healthy subjects with normal ECG, left bundle branch block (LBBB), and right bundle branch block (RBBB) patients. Then we created UHF-ECG and ND-ECG-derived depolarization maps and computed interventricular electrical dyssynchrony. Characteristic spatio-temporal differences were found between the volumetric UHF-ECG activation patterns and epicardial ND-ECG in the Normal, LBBB, and RBBB groups, despite the overall high correlations between both methods. Interventricular electrical dyssynchrony values assessed by the ND-ECG were consistently larger than values computed by the UHF-ECG method. Noninvasively obtained UHF-ECG and ND-ECG analyses describe different ventricular dyssynchrony and the general course of ventricular depolarization. Combining both methods based on standard 12-lead ECG electrode positions allows for a more detailed analysis of volumetric and epicardial ventricular electrical activation, including the assessment of the depolarization wave direction propagation in ventricles.
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Affiliation(s)
- Pavel Leinveber
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic.
| | - Josef Halamek
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Karol Curila
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Frits Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Jolana Lipoldova
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Magdalena Matejkova
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Radovan Smisek
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
- Department of Biomedical Engineering, Faculty of Electrical Engineering and Communication, Brno University of Technology, Brno, Czech Republic
| | - Filip Plesinger
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Andrej Nagy
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Miroslav Novak
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ivo Viscor
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Vlastimil Vondra
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Pavel Jurak
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
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Sciarra L, Golia P, Scarà A, Robles AG, De Maio M, Palamà Z, Borrelli A, Di Roma M, D'Arielli A, Calò L, Gallina S, Ricci F, Delise P, Zorzi A, Nesti M, Romano S, Cavarretta E. Electrocardiographic predictors of left ventricular scar in athletes with right bundle branch block premature ventricular beats. Eur J Prev Cardiol 2024; 31:486-495. [PMID: 38198223 DOI: 10.1093/eurjpc/zwae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/03/2024] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
AIMS Right bundle branch block (RBBB) morphology non-sustained ventricular arrhythmias (VAs) have been associated with the presence of non-ischaemic left ventricular scar (NLVS) in athletes. The aim of this cross-sectional study was to identify clinical and electrocardiogram (ECG) predictors of the presence of NLVS in athletes with RBBB VAs. METHODS AND RESULTS Sixty-four athletes [median age 39 (24-53) years, 79% males] with non-sustained RBBB VAs underwent cardiac magnetic resonance (CMR) with late gadolinium enhancement in order to exclude the presence of a concealed structural heart disease. Thirty-six athletes (56%) showed NLVS at CMR and were assigned to the NLVS positive group, whereas 28 athletes (44%) to the NLVS negative group. Family history of cardiomyopathy and seven different ECG variables were statistically more prevalent in the NLVS positive group. At univariate analysis, seven ECG variables (low QRS voltages in limb leads, negative T waves in inferior leads, negative T waves in limb leads I-aVL, negative T waves in precordial leads V4-V6, presence of left posterior fascicular block, presence of pathologic Q waves, and poor R-wave progression in right precordial leads) proved to be statistically associated with the finding of NLVS; these were grouped together in a score. A score ≥2 was proved to be the optimal cut-off point, identifying NLVS athletes in 92% of cases and showing the best accuracy (86% sensitivity and 100% specificity, respectively). However, a cut-off ≥1 correctly identified all patients with NLVS (absence of false negatives). CONCLUSION In athletes with RBBB morphology non-sustained VAs, specific ECG abnormalities at 12-lead ECG can help in detecting subjects with NLVS at CMR.
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Affiliation(s)
- Luigi Sciarra
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, piazzale Salvatore Tommasi 1, 67100 Coppito (AQ), Italy
| | - Paolo Golia
- Department of Cardiology, Policlinico Casilino Hospital, Rome, Italy
| | - Antonio Scarà
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, piazzale Salvatore Tommasi 1, 67100 Coppito (AQ), Italy
- Department of Cardiology, San Carlo di Nancy Hospital, Rome, Italy
| | - Antonio Gianluca Robles
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, piazzale Salvatore Tommasi 1, 67100 Coppito (AQ), Italy
| | - Melissa De Maio
- Department of Cardiology, Policlinico Casilino Hospital, Rome, Italy
| | - Zefferino Palamà
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, piazzale Salvatore Tommasi 1, 67100 Coppito (AQ), Italy
| | - Alessio Borrelli
- Department of Cardiology, San Carlo di Nancy Hospital, Rome, Italy
| | - Mauro Di Roma
- Department of Radiology, Policlinico Casilino Hospital, Rome, Italy
| | - Alberto D'Arielli
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, piazzale Salvatore Tommasi 1, 67100 Coppito (AQ), Italy
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino Hospital, Rome, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Pietro Delise
- Division of Cardiology, Hospital 'P. Pederzoli', Peschiera del Garda 37019, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, Padova 35121, Italy
| | - Martina Nesti
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, piazzale Salvatore Tommasi 1, 67100 Coppito (AQ), Italy
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124 Pisa, Italy
| | - Silvio Romano
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, piazzale Salvatore Tommasi 1, 67100 Coppito (AQ), Italy
| | - Elena Cavarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, corso della Repubblica 79, 04100 Latina, Italy
- Mediterranea Cardiocentro, Via Orazio, 2, 80122 Napoli, Italy
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Ghazal R, Garabedian H, Sawaya F, Refaat MM. Post-TAVR conduction abnormalities leading to permanent pacemaker implantation: Risk factors, prevention, and management. J Cardiovasc Electrophysiol 2024; 35:488-497. [PMID: 38254339 DOI: 10.1111/jce.16185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/26/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Transcatheter aortic valve replacement (TAVR) often leads to conduction abnormalities, necessitating pacemaker implantation. This review of 38 meta-analyses identified preexisting right bundle branch block (RBBB), LAHB, and new-onset left bundle branch block as key risk factors, with a higher PPM risk in male and older patients. Procedural factors like transfemoral access and self-expandable valves also increase this risk. Prevention focuses on tailoring TAVR to individual electrophysiological and anatomical profiles. However, there's a lack of consensus in managing these conduction disturbances post-TAVR, highlighting the need for further research and standardized treatment strategies.
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Affiliation(s)
- Rachad Ghazal
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Fadi Sawaya
- Structural Heart and Valve Division, American University of Beirut Medical Center, Beirut, Lebanon
- Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marwan M Refaat
- Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
- Cardiac Electrophysiology Division, American University of Beirut Medical Center, Beirut, Lebanon
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11
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Lee JH. Discrimination between ventricular tachycardia and wide-QRS preexcited tachycardia. Ann Noninvasive Electrocardiol 2024; 29:e13112. [PMID: 38491719 PMCID: PMC10943251 DOI: 10.1111/anec.13112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND To develop a new algorithm to differentiate ventricular tachycardia (VT) from preexcited tachycardia (pre-ET) according to left bundle branch block (LBBB) and right bundle branch block (RBBB) patterns. METHODS This study included 67 electrocardiograms (ECGs) with VT and 63 ECGs with pre-ET, collected from our hospital and through PubMed. Of those, 64 were allocated to the derivation cohort and the rest to the validation cohort. The diagnoses of the ECGs were confirmed using an electrophysiological study. Parameters and classifiers from prior algorithms along with the propagation speeds in the early portion of the QRS complex (initial deflection index) in leads V1, V6, aVR, II, and III were manually measured. The performance of the new algorithm was compared with that of prior algorithms. RESULTS The initial deflection index in lead III was the strongest predictor of pre-ET in LBBB-pattern wide-QRS tachycardia (p = 0.003, AUC 0.805). The initial deflection index in lead V1 was the most powerful predictor of pre-ET in RBBB-pattern wide-QRS tachycardia (p = 0.001, AUC 0.848). Compared to earlier algorithms, those using the initial deflection indexes: lead III in LBBB patterns (cutoff value >0.3) and lead V1 in RBBB patterns (cutoff value ≤0.48), demonstrated superior performance in screening VT, with AUC values of 0.828. The initial deflection indexes proved effective as discriminators between VT and pre-ET in the validation cohort. CONCLUSIONS In LBBB-pattern wide-QRS tachycardia, the early propagation speed of pre-ET was faster than that in VT. Conversely, in RBBB-pattern wide-QRS tachycardia, it was slower.
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Affiliation(s)
- Jae Hoon Lee
- Department of Emergency MedicineDong‐A University College of MedicineBusanSouth Korea
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12
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Obregón-Rosas S, García-Almazán D, Flores-Pérez CS, Sotelo-Lozano MT, De Sandoval-Martínez E, Hernández-Alcaraz FC, López-Mota LA, Martínez-Estrada MA, Oroz-Domínguez AS, Montañez-Aguirre ÁA, Romero-García de Acevedo LE, Acosta-Castro I, Pérez-Rubio Flores R, Ortega-Cerda JJ. Comprehensive analysis of right fascicular and right bundle branch blocks: A multi-center study. J Electrocardiol 2024; 83:95-105. [PMID: 38387106 DOI: 10.1016/j.jelectrocard.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 02/24/2024]
Abstract
Electrocardiographic patterns of right bundle branch and fascicular blocks were comprehensively analyzed in a two-phase study. The research aimed to address the scarcity of literature and the absence of standardized diagnostic criteria for these conditions. It revealed a weak correlation between the cardiac axis and age and highlighted the high misdiagnosis rate of these blocks. Furthermore, it discussed the challenges in fulfilling existing diagnostic criteria. The study emphasizes the need for a more precise understanding of right ventricular conduction disorders and the importance of developing robust diagnostic criteria.
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Affiliation(s)
- Santiago Obregón-Rosas
- Mexican Faculty of Medicine, La Salle University, Mexico City, Mexico; Hospital Angeles Pedregal, Mexico City, Mexico.
| | | | | | | | | | | | | | | | - Aranza Sara Oroz-Domínguez
- Mexican Faculty of Medicine, La Salle University, Mexico City, Mexico; Hospital General Ajusco Medio, Mexico City, Mexico
| | | | | | - Itzayana Acosta-Castro
- Mexican Faculty of Medicine, La Salle University, Mexico City, Mexico; Hospital Angeles Mexico, Mexico City, Mexico
| | | | - José Juan Ortega-Cerda
- Professor Emeritus, Mexican Faculty of Medicine, La Salle University, Mexico City, Mexico; Director of Teaching and Research, Hospital Angeles Health System, Mexico City, Mexico; Hospital Angeles Pedregal, Mexico City, Mexico.
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13
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Manne M, Niebauer M, Tchou P, Varma N. LBBB and heart failure-Relationships among QRS amplitude, duration, height, LV mass, and sex. J Cardiovasc Electrophysiol 2024; 35:583-591. [PMID: 37811553 DOI: 10.1111/jce.16097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Height, left ventricular (LV) size, and sex were proposed as additional criteria for patient selection for cardiac resynchronization therapy (CRT) but their connections with the QRS complex in left bundle branch block (LBBB) are little investigated. We evaluated these. METHODS Among patients with "true" LBBB, QRS duration (QRSd) and amplitude, and LV hypertrophy indices, were correlated with patient's height and LV mass, and compared between sexes. RESULTS In this study cohort (n = 220; 60 ± 12 years; left ventricular ejection fraction [LVEF] 21 ± 7%; mostly New York Heart Association II-III, QRSd 165 ± 19 ms; 57% female; 70% responders [LVEF increased ≥5%]), LV mass was increased in all patients. QRS amplitude did not correlate with LV mass or height in any individual lead or with Sokolow-Lyon or Cornell-Lyon indices. QRSd did not correlate with height. In contrast, QRSd correlated strongly with LV mass (r = .51). CRT response rate was greater in women versus men (84% vs. 58%, p < .001) despite shorter QRSd [7% shorter (p < .0001)]. QRSd normalized for height resulted in a 2.7% and for LV mass 24% greater index in women. CONCLUSION True LBBB criteria do not exclude HF patients with increased LV mass. QRS amplitudes do not correlate with height or LV mass. Height does not affect QRSd. However, QRSd correlates with LV size. QRSd normalized for LV mass results in 24% greater value in women in the direction of sex-specific responses. LV mass may be a significant nonelectrical modifier of QRSd for CRT.
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Affiliation(s)
- Mahesh Manne
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Niebauer
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick Tchou
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Niraj Varma
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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14
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Liu X, Li M, Chen J, Wu J, Zhang L, Hu J, Li F, Fan X, Yang H, Yan L, Liu J. Association between left bundle branch block and ventricular septal mid-wall fibrosis in patients with preserved left ventricular ejection fraction. J Electrocardiol 2024; 83:21-25. [PMID: 38241779 DOI: 10.1016/j.jelectrocard.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/29/2023] [Accepted: 01/07/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND The left bundle branch block (LBBB) is associated with ventricular septal mid-wall fibrosis (SMF) in patients with dilated cardiomyopathy (DCM). However, whether LBBB is also associated with SMF in patients with preserved left ventricular ejection fraction (LVEF) remains unclear. METHODS We performed a retrospective study of 210 patients with preserved LVEF (male, n = 116; female, n = 94; mean age, 44 ± 17 years). LBBB was defined as QRS duration ≥140 ms for men or ≥ 130 ms for women, QS or rS in V1-V2, mid-QRS notching or slurring in at least two leads (V1, V2, V5, V6, I, and aVL). SMF determined by late gadolinium-enhancement cardiovascular magnetic resonance was defined as stripe-like or patchy mid-myocardial hyper-enhancement in the interventricular septal segments. RESULTS SMF was detected in 24.8% (52/210) of these patients. The proportion of patients with SMF with LBBB was higher than the proportion of patients with SMF without LBBB (58.3% vs. 20.4%; P < 0.001). In the forward multivariate logistic analysis, LBBB (OR, 4.399; 95% CI, 1.774-10.904; P = 0.001) and age (OR, 1.028; 95% CI, 1.006-1.051; P = 0.011) were independently associated with SMF. The presence of LBBB showed a sensitivity of 27%%, specificity of 94%, positive predictive value of 58%%, and negative predictive value of 80% for the detection of SMF. CONCLUSION LBBB was significantly associated with SMF in hospitalized patients with preserved LVEF. Screening with a resting 12‑lead ECG may help to identify patients who are at a high risk of the presence of SMF.
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Affiliation(s)
- Xiaojie Liu
- Department of Cardiology, Henan University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Muzhang Li
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiaying Chen
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Jintao Wu
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China.
| | - Leiming Zhang
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Juan Hu
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Feifei Li
- Human Resource Department, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xianwei Fan
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Haitao Yang
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijie Yan
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingjing Liu
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
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15
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Tomcsányi J. [Painful left bundle branch block]. Orv Hetil 2024; 165:232-235. [PMID: 38341834 DOI: 10.1556/650.2024.32964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/21/2023] [Indexed: 02/13/2024]
Abstract
A szerző egy esetet mutat be, amelynél a frekvenciadependens
bal-Tawara-szár-blokk típusos effortanginás panaszt okoz ép coronariák mellett.
A terheléses EKG-vizsgálat kiváltotta az angina pectorist, és ezzel szinkrón
komplett bal-Tawara-szár-blokk jelentkezett az EKG-n. A terhelés után mind a
bal-Tawara-szár-blokk, mind az anginás panasz megszűnt. A beteg panaszai és
bal-Tawara-szár-blokkja az ivabradin és trimetazidin kombinált kezelés mellett a
későbbiekben nem jelentkezett. A szerző az eset kapcsán tárgyalja a fájdalmas
bal-Tawara-szár-blokk lehetséges patomechanizmusát és a kezelési lehetőségeket.
Orv Hetil. 2024; 165(6): 232–235.
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Affiliation(s)
- János Tomcsányi
- 1 Betegápoló Irgalmasrend Budai Irgalmasrendi Kórháza, Kardiológia Budapest, Árpád fejedelem u. 7., 1023 Magyarország
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16
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Nguyên UC, Prinzen FW, Vernooy K. Left ventricular lead placement in cardiac resynchronization therapy: Current data and potential explanations for the lack of benefit. Heart Rhythm 2024; 21:197-205. [PMID: 37806647 DOI: 10.1016/j.hrthm.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
The present article reviews the literature on image-guided cardiac resynchronization therapy (CRT) studies. Improved outcome to CRT has been associated with the placement of a left ventricular (LV) lead in the latest activated segment free from scar. The majority of randomized controlled trials investigating guided LV lead implantation did not show superiority over conventional implantation approaches. Several factors may contribute to this paradoxical observation, including inclusion criteria favoring patients with left bundle branch block who already respond well to conventional anatomical LV lead implantation, differences in activation wavefronts during simultaneous right ventricular and LV pacing, incorrect definition of target regions, and limitations in coronary venous anatomy that prevent access to target regions that are detected by imaging. It is imperative that exclusion of patients lacking access to target regions from these studies would lead to larger benefit of image-guided CRT.
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Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.
| | - Frits W Prinzen
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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17
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Tan NY, Adedinsewo D, El Sabbagh A, Sayed Ahmed AF, Carolina Morales-Lara A, Wieczorek M, Madhavan M, Mulpuru SK, Deshmukh AJ, Asirvatham SJ, Eleid MF, Friedman PA, Cha YM, Killu AM. Incidence and Outcomes of New-Onset Right Bundle Branch Block Following Transcatheter Aortic Valve Replacement. Circ Arrhythm Electrophysiol 2024; 17:e012377. [PMID: 38288627 DOI: 10.1161/circep.123.012377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/02/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND The incidence and prognosis of right bundle branch block (RBBB) following transcatheter aortic valve replacement (TAVR) are unknown. Hence, we sought to characterize the incidence of post-TAVR RBBB and determine associated risks of permanent pacemaker (PPM) implantation and mortality. METHODS All patients 18 years and above without preexisting RBBB or PPM who underwent TAVR at US Mayo Clinic sites and Mayo Clinic Health Systems from June 2010 to May 2021 were evaluated. Post-TAVR RBBB was defined as new-onset RBBB in the postimplantation period. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. RESULTS Of 1992 patients, 15 (0.75%) experienced new RBBB post-TAVR. There was a higher degree of valve oversizing among patients with new RBBB post-TAVR versus those without (17.9% versus 10.0%; P=0.034). Ten patients (66.7%) with post-TAVR RBBB experienced high-grade atrioventricular block and underwent PPM implantation (median 1 day; Q1, 0.2 and Q3, 4), compared with 268/1977 (13.6%) without RBBB. Following propensity score adjustment for covariates (age, sex, balloon-expandable valve, annulus diameter, and valve oversizing), post-TAVR RBBB was significantly associated with PPM implantation (hazard ratio, 8.36 [95% CI, 4.19-16.7]; P<0.001). No statistically significant increase in mortality was seen with post-TAVR RBBB (hazard ratio, 0.83 [95% CI, 0.33-2.11]; P=0.69), adjusting for age and sex. CONCLUSIONS Although infrequent, post-TAVR RBBB was associated with elevated PPM implantation risk. The mechanisms for its development and its clinical prognosis require further study.
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Affiliation(s)
- Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
| | | | | | | | | | - Mikolaj Wieczorek
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL (M.W.)
| | - Malini Madhavan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
| | - Siva K Mulpuru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
| | - Abhishek J Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.Y.T., M.M., S.K.M., A.J.D., S.J.A., M.F.E., P.A.F., Y.-M.C., A.M.K.)
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Zhang X, Liang C, Zha L, Zuo Q, Hu G, Ding J, Tang S. Predictors for new-onset conduction block in patients with pure native aortic regurgitation after transcatheter aortic valve replacement with a new-generation self-expanding valve (VitaFlow Liberty ™): a retrospective cohort study. BMC Cardiovasc Disord 2024; 24:77. [PMID: 38281925 PMCID: PMC10822180 DOI: 10.1186/s12872-024-03735-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/17/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND New-generation self-expanding valves can improve the success rate of transcatheter aortic valve replacement (TAVR) for severe pure native aortic regurgitation (PNAR). However, predictors of new-onset conduction block post-TAVR using new-generation self-expanding valves in patients with PNAR remain to be established. Therefore, this study aimed to identify predictors of new-onset conduction block post-TAVR using new-generation self-expanding valves (VitaFlow Liberty™) in patients with PNAR. METHODS In this retrospective cohort study, patients were categorized into pacemaker and non-pacemaker groups based on their need for new postoperative permanent pacemaker implantation (PPI). Based on the postoperative presence of either new-onset complete left bundle branch block (cLBBB) or high-grade atrioventricular block (AVB), patients were further classified into conduction disorder and non-conduction disorder groups. Laboratory, echocardiographic, computed tomography, preoperative and postoperative electrocardiography, and procedural and clinical data were collected immediately after TAVR and during hospitalization and compared between the groups. Multivariate logistic regression analysis was performed incorporating the significant variables from the univariate analyses. RESULTS This study examined 68 consecutive patients with severe PNAR who underwent TAVR. In 20 patients, a permanent pacemaker was fitted postoperatively. Multivariate logistic regression analysis revealed an association between the need for postoperative PPI and preoperative complete right bundle branch block (cRBBB) or first-degree AVB, as well as a non-tubular left ventricular outflow tract (LVOT). In addition, valve implantation depth and angle of aortic root were independent predictors of new-onset cLBBB or high-grade AVB developing post-TAVR. The predictive value of valve implantation depth and angle of aortic root was further supported by receiver operating characteristic curve analysis results. CONCLUSIONS In patients with PNAR undergoing TAVR using self-expanding valves, preoperative cRBBB or first-degree AVB and a non-tubular LVOT were indicators of a higher likelihood of PPI requirement. Moreover, deeper valve implantation depth and greater angle of aortic root may be independent risk factors for new-onset cLBBB or high-grade AVB post-TAVR. Valve implantation depth and angle of aortic root values may be used to predict the possibility of new cLBBB or high-grade AVB post-TAVR.
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Affiliation(s)
- Xuan Zhang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, No. 2, Zheshan West Road, Jinghu District, Wuhu City, Anhui Province, China
| | - Cheng Liang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, No. 2, Zheshan West Road, Jinghu District, Wuhu City, Anhui Province, China
| | - Lintao Zha
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, No. 2, Zheshan West Road, Jinghu District, Wuhu City, Anhui Province, China.
| | - Quan Zuo
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, No. 2, Zheshan West Road, Jinghu District, Wuhu City, Anhui Province, China
| | - Guobing Hu
- Department of Ultrasound Medicine, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui, China
| | - Jie Ding
- Department of Ultrasound Medicine, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui, China
| | - Shengxing Tang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, No. 2, Zheshan West Road, Jinghu District, Wuhu City, Anhui Province, China.
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19
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Lindow T, Mokhtari A, Nyström A, Koul S, Smith SW, Ekelund U. Comparison of diagnostic accuracy of current left bundle branch block and ventricular pacing ECG criteria for detection of occlusion myocardial infarction. Int J Cardiol 2024; 395:131569. [PMID: 37931659 DOI: 10.1016/j.ijcard.2023.131569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Electrocardiographic detection of patients with occlusion myocardial infarction (OMI) can be difficult in patients with left bundle branch block (LBBB) or ventricular paced rhythm (VPR) and several ECG criteria for the detection of OMI in LBBB/VPR exist. Most recently, the Barcelona criteria, which includes concordant ST deviation and discordant ST deviation in leads with low R/S amplitudes, showed superior diagnostic accuracy but has not been validated externally. We aimed to describe the diagnostic accuracy of four available ECG criteria for OMI detection in patients with LBBB/VPR at the emergency department. METHODS The unweighted Sgarbossa criteria, the modified Sgarbossa criteria (MSC), the Barcelona criteria and the Selvester criteria were applied to chest pain patients with LBBB or VPR in a prospectively acquired database from five emergency departments. RESULTS In total, 623 patients were included, among which 441 (71%) had LBBB and 182 (29%) had VPR. Among these, 82 (13%) patients were diagnosed with AMI, and an OMI was identified in 15 (2.4%) cases. Sensitivity/specificity of the original unweighted Sgarbossa criteria were 26.7/86.2%, for MSC 60.0/86.0%, for Barcelona criteria 53.3/82.2%, and for Selvester criteria 46.7/88.3%. In this setting with low prevalence of OMI, positive predictive values were low (Sgarbossa: 4.6%; MSC: 9.4%; Barcelona criteria: 6.9%; Selvester criteria: 9.0%) and negative predictive values were high (all >98.0%). CONCLUSIONS Our results suggests that ECG criteria alone are insufficient in predicting presence of OMI in an ED setting with low prevalence of OMI, and the search for better rapid diagnostic instruments in this setting should continue.
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Affiliation(s)
- Thomas Lindow
- Clinical Physiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Clinical Physiology, Department of Research and Development, Region Kronoberg, Växjö Central Hospital, Växjö, Sweden.
| | - Arash Mokhtari
- Department of Cardiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Axel Nyström
- Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Stephen W Smith
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ulf Ekelund
- Emergency Medicine, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Emergency Medicine, Skåne University Hospital, Lund, Sweden
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20
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Alboni P, Holzl A, Baggioni GF. [Tall R waves in the right precordial leads as a possible expression of left septal fascicular block]. G Ital Cardiol (Rome) 2024; 25:22-25. [PMID: 38140994 DOI: 10.1714/4165.41588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Histological, physiological and pathophysiological studies have shown that the left bundle branch mainly divides into three fascicles, and a septal (middle) fascicle is present in over half of human hearts. Electrocardiographic criteria for the diagnosis of the block of this fascicle have been suggested by some authors: tall R waves in lead V2 and sometimes in V1 in the absence of a right bundle branch block pattern or a well evident jump of R waves from V1 to V2, absence of initial septal q waves and/or possible small q waves in the right precordial leads, normal QRS duration and normal QRS axis. At present, this intraventricular block can only be suspected but not diagnosed with certainty even after clinical/instrumental exclusion of pathological situations associated with tall R waves in leads V1 and V2 (right ventricular hypertrophy, lateral infarction, severe septal hypertrophy) because of the marked variability of normal ECG and the potential presence of confounding diseases.
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Affiliation(s)
- Paolo Alboni
- Sezione di Cardiologia, Ospedale Accreditato Quisisana, Ferrara
| | - Anna Holzl
- Sezione di Cardiologia, Ospedale Accreditato Quisisana, Ferrara
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Kojo K, Morikawa T, Kikawa T, Sasaki K, Suyama Y, Shimizu T. Diagnostic Dilemma of Syncope: Esophageal Hiatal Hernia and High-risk Bundle-branch Block. Intern Med 2024; 63:83-86. [PMID: 37197958 PMCID: PMC10824654 DOI: 10.2169/internalmedicine.1569-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/16/2023] [Indexed: 05/19/2023] Open
Abstract
We herein report a complicated case of recurrent syncope accompanying bundle branch block and hiatal hernia of the esophagus. An 83-year-old woman presented with syncope. Echocardiography visualized the left atrium compressed by an esophageal hiatal hernia, which had potential to decrease the cardiac output. Although she underwent esophageal repair surgery, two months after the surgery, she presented to the emergency department again with complaints of syncope. At the return visit, her face was pale and her pulse rate was 30 beats per minute. Electrocardiography showed complete atrioventricular block. On reviewing the patient's previous electrocardiography findings, we found a record of trifascicular block. This case illustrates the importance of predicting atrioventricular blocks in patients with high-risk bundle-branch blocks. Keeping in mind high-risk bundle-branch blocks will help clinicians avoid anchoring bias due to a striking image masquerading as the true diagnosis.
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Affiliation(s)
- Kenshiro Kojo
- Department of General Medicine, Nara City Hospital, Japan
| | - Toru Morikawa
- Department of General Medicine, Nara City Hospital, Japan
| | - Tomoko Kikawa
- Department of Cardiovascular Medicine, Nara City Hospital, Japan
| | - Kantaro Sasaki
- Department of General Medicine, Nara City Hospital, Japan
| | | | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Japan
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22
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Briongos-Figuero S, Estévez-Paniagua Á, Sánchez-Hernández A, Heredero-Palomo D, Sánchez-López E, Luna-Cabadas A, Tapia-Martínez M, Muñoz-Aguilera R. Tailored electrocardiographic-based criteria for different pacing locations within the left bundle branch. Heart Rhythm 2024; 21:54-63. [PMID: 37741525 DOI: 10.1016/j.hrthm.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/06/2023] [Accepted: 09/17/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Electrocardiographic (ECG)-based criteria are used to confirm left bundle branch (LBB) pacing (LBBP), but current cutoff values have never been validated for different pacing locations. OBJECTIVE The purpose of this study was to describe diagnostic performance of V6-R wave peak time (RWPT), V6-V1 interpeak interval, and aVL-RWPT for different pacing sites within the LBB and to determine 100% specific values for each criterion at each pacing location. METHODS Consecutive patients with confirmed LBBP were selected. Population was divided into subgroups based on the site of pacing: left bundle trunk pacing (LBTP), left septal fascicular pacing (LSFP), left posterior fascicular pacing (LPFP), and left anterior fascicular pacing (LAFP). RESULTS A total of 147 patients with unequivocal LBB capture were analyzed. Left fascicular pacing was more frequently achieved (82.8%) than LBTP (17.2%). Diagnostic performance of V6-RWPT, V6-V1 interpeak interval, and aVL-RWPT for discrimination of LBBP was good in all subgroups. V6-RWPT cutoff values with 100% specificity (SP) for LBBP discrimination were 75 ms in LBTP, 68 ms in LPFP, 81 ms in LAFP, and 79.5 ms in LSFP. V6-V1 interpeak interval cutoff values with 100% SP for LBBP discrimination were 35.5 ms in LBTP, 53.5 ms in LPFP, 41 ms in LAFP, and 46 ms in LSFP. In LAFP, aVL-RWPT cutoff value with 100% SP for LBBP discrimination was 68 ms, but was 74 ms in LBTP, 74.5 ms in LSFP, and 73.5 ms in LPFP. CONCLUSIONS Tailored ECG-based criteria might be useful to confirm LBBP at different pacing locations within the LBB.
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Laenens D, Stassen J, Galloo X, Myagmardorj R, Marsan NA, Bax JJ. Association Between Left Ventricular Apical-to-Basal Strain Ratio and Conduction Disorders after Aortic Valve Replacement. J Am Soc Echocardiogr 2024; 37:77-86. [PMID: 37730096 DOI: 10.1016/j.echo.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/01/2023] [Accepted: 09/11/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND The aim of the study was to evaluate whether left ventricular apical-to-basal longitudinal strain differences, representing advanced basal interstitial fibrosis, are associated with conduction disorders after aortic valve replacement (AVR) in patients with severe aortic stenosis. METHODS Patients with aortic stenosis undergoing AVR were included. The apical-to-basal strain ratio was calculated by dividing the average strain of the apical segments by the average strain of the basal segments. Values >1.9 were considered abnormal, as previously described. All patients were followed up for the occurrence of complete left or right bundle branch block or permanent pacemaker implantation within 2 years after AVR. Subgroup analysis was performed in patients undergoing transcatheter AVR. RESULTS Two hundred seventy-four patients were included (median age of 74 years [interquartile range, 65, 80], 46.4% male). During a median follow-up of 12.2 months (interquartile range, 0.2, 24.3), 74 patients (27%) developed complete bundle branch block or were implanted with a permanent pacemaker. These patients more often had an abnormal apical-to-basal strain ratio. Cumulative event-free survival analysis showed worse outcome in patients with an abnormal apical-to-basal strain ratio (log rank χ2 = 7.258, P = .007). In multivariable Cox regression analysis, an abnormal apical-to-basal strain ratio was the only independent factor associated with the occurrence of complete bundle branch block or permanent pacemaker implantation after adjusting for other factors previously shown to be associated with conduction disorders after AVR. Subgroup analysis confirmed the independent association of an abnormal apical-to-basal strain ratio with conduction disorders after transcatheter AVR. CONCLUSION The apical-to-basal strain ratio is independently associated with conduction disorders after AVR and could guide risk stratification in patients potentially at risk for pacemaker implantation.
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Affiliation(s)
- Dorien Laenens
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Xavier Galloo
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, University Hospital Brussels, Jette, Belgium
| | | | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Turku Heart Center, University of Turku and Turku University Hospital, Turku, Finland.
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Cano Ó, Jover P, Ayala HD, Navarrete-Navarro J, Osca J, Izquierdo M, Navarro J, Martínez-Dolz L. Left bundle branch pacing versus left ventricular septal pacing as a primary procedural endpoint during left bundle branch area pacing: Evaluation of two different implant strategies. J Cardiovasc Electrophysiol 2024; 35:120-129. [PMID: 37962088 DOI: 10.1111/jce.16128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/12/2023] [Accepted: 10/28/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION Implant procedure features and clinical implications of left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP) have not been yet fully described. We sought to compare two different left bundle branch area pacing (LBBAP) implant strategies: the first one accepting LVSP as a procedural endpoint and the second one aiming at achieving LBBP in every patient in spite of evidence of previous LVSP criteria. METHODS LVSP was accepted as a procedural endpoint in 162 consecutive patients (LVSP strategy group). In a second phase, LBBP was attempted in every patient in spite of achieving previous LVSP criteria (n = 161, LBBP strategy group). Baseline patient characteristics, implant procedure, and follow-up data were compared. RESULTS The final capture pattern was LBBP in 71.4% and LVSP in 24.2% in the LBBP strategy group compared to 42.7% and 50%, respectively, in the LVSP strategy group. One hundred and eighty-four patients (57%) had proven LBB capture criteria with a significantly shorter paced QRS duration than the 120 patients (37%) with LVSP criteria (115 ± 9 vs. 121 ± 13 ms, p < .001). Implant parameters were comparable between the two strategies but the LBBP strategy resulted in a higher rate of acute septal perforation (11.8% vs. 4.9%, p = .026) without any clinical sequelae. Patients with CRT indications significantly improved left ventricular ejection fraction (LVEF) during follow-up irrespective of the capture pattern (from 35 ± 11% to 45 ± 14% in proven LBBP, p = .024; and from 39 ± 13% to 47 ± 12% for LVSP, p = .003). The presence of structural heart disease and baseline LBBB independently predicted unsuccessful LBB capture. CONCLUSION The LBBP strategy was associated with comparable implant parameters than the LVSP strategy but resulted in higher rates of septal perforation. Proven LBB capture and LVSP showed comparable effects on LVEF during follow-up.
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Affiliation(s)
- Óscar Cano
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Spain
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Pablo Jover
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Hebert D Ayala
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Javier Navarrete-Navarro
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Joaquín Osca
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Spain
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Maite Izquierdo
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Spain
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Josep Navarro
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Luis Martínez-Dolz
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Spain
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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Perel N, Tovia-Brodie O, Schnur A, Acha MR, Levi N, Cohen Y, Dvir D, Glikson M, Michowitz Y. Post-transcatheter aortic valve implantation isolated PR prolongation: incidence and clinical significance. Europace 2023; 26:euae011. [PMID: 38225168 PMCID: PMC10808043 DOI: 10.1093/europace/euae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/08/2024] [Indexed: 01/17/2024] Open
Abstract
AIMS Conduction abnormalities post-transcatheter aortic valve implantation (TAVI) are common. Post-TAVI PR prolongation was mainly studied as an adjunct to new-onset bundle branch block. The net effect of isolated PR prolongation (IPRP) without post-TAVI QRS changes is not well known. The aim of this study was to define the incidence and clinical significance of post-TAVI IPRP. METHODS AND RESULTS A total of 1108 consecutive TAVI patients were reviewed. Patients with IPRP were compared with patients without post-TAVI electrocardiogram (ECG) changes. Clinical outcomes included permanent pacemaker implantation (PPI) and overall mortality. A total of 146 patients with IPRP were compared with 290 patients without post-TAVI ECG changes. At 1 year follow-up, 4 (2.7%) and 7 (2.4%) patients underwent PPI (P = 0.838) and 10 (6.8%) and 25 (8.6%) died (P = 0.521), from the study and control groups, respectively. No patient with IPRP and narrow QRS underwent PPI during 1 year post-TAVI, and all death events were non-cardiac except one unknown cause. Permanent pacemaker implantation rates among patients with IPRP and wide QRS were higher (n = 4, 12.1%), compared with patients with wide QRS without post-TAVI ECG change (n = 3, 4%) however not reaching statistical significance (P = 0.126). Multivariate Cox proportional hazards model demonstrated that in patients with narrow QRS, neither PR prolongation nor baseline or maximal PR intervals was associated with the combined endpoint of PPI and mortality. However, in patients with wide QRS, baseline PR intervals and QRS width, but not PR prolongation were associated with the combined outcome. CONCLUSION Post-TAVI IPRP in patients with narrow QRS is not associated with adverse outcome. This finding may translate clinically into a more permissive approach to these patients.
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Affiliation(s)
- Nimrod Perel
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Oholi Tovia-Brodie
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Asher Schnur
- Department of Internal Medicine C, Shaare Zedek Medical Center,12 Shmuel Beit Street, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Moshe Rav Acha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Nir Levi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Yogev Cohen
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Danny Dvir
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Yoav Michowitz
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Erdem A, Torun A. Misplacement of pacemaker leads: How to avoid and how to approach? Pacing Clin Electrophysiol 2023; 46:1662-1664. [PMID: 37910444 DOI: 10.1111/pace.14865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/14/2023] [Accepted: 10/22/2023] [Indexed: 11/03/2023]
Abstract
The use of cardiac implantable electronic devices has increased in recent years due to factors such as a growing population, increased life expectancy, and improved access to healthcare services. In parallel with this trend, complications related to pacemakers have also increased. One of the most important and preventable complications among these is lead misplacement. Misplacement of a permanent pacemaker lead in the LV can lead to a variety of complications, including damage to the heart muscle, arrhythmias, blood clotes and cerebrovascular events. It is recommended to use the fluoroscopic 40° LAO view during implantation. That view clearly defines the interatrial and interventricular septum. Right bundle branch block pattern on ECG is an important clue to suspected misplaced lead. In addition to the postero-anterior (PA) projection of x-ray, the latero-lateral (LL) projection provides a clearer view of lead malposition. In the LL view, the tip of an incorrectly positioned LV lead is characteristically directed toward the spine. If diagnosed soon after implantation, percutaneous lead extraction can reduce the risk of future thromboembolic events without the need for lifelong anticoagulation. It should be noted that in cases with a lead in the LV for a long time, lead removal is not the primary recommendation. Patient-based approach should be fundamental.
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Affiliation(s)
- Almina Erdem
- Department of Cardiology, Health Sciences University, Sultan II. Abdülhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Akin Torun
- Department of Cardiology, Health Sciences University, Sultan II. Abdülhamid Han Training and Research Hospital, Istanbul, Turkey
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Ravi V, Vipparthy S, Sanders DJ, Huang H, Larsen T, Trohman R, Vijayaraman P, Sharma PS. Novel Intraprocedural Assessment of the Optimal Modality for Cardiac Resynchronization in Patients With LBBB/IVCD Pattern. JACC Clin Electrophysiol 2023; 9:2652-2654. [PMID: 37855767 DOI: 10.1016/j.jacep.2023.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Venkatesh Ravi
- Saint Francis Cardiology, Saint Francis Health System, Tulsa, Oklahoma, USA
| | - Sharath Vipparthy
- Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, Illinois, USA
| | - David J Sanders
- Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Henry Huang
- Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy Larsen
- Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Richard Trohman
- Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Parikshit S Sharma
- Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, Illinois, USA.
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Jin P, Jiao P, Feng J, Shi L, Ma L. The predictive value of abnormal electrocardiogram for patent foramen ovale: A retrospective study. Clin Cardiol 2023; 46:1504-1510. [PMID: 37667505 PMCID: PMC10716327 DOI: 10.1002/clc.24133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND AND HYPOTHESIS The objective of this study was to identify the characteristics of electrocardiogram (ECG) in adult patients with patent foramen ovale (PFO) and to analyze the predictive value of the characteristics of ECG for PFO in adult patients. METHODS Retrospectively, 267 patients who had undergone ECG, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) with agitated saline contrast echocardiography in our hospital, were recruited continuously from January 2021 to March 2023. Electrocardiographs were analyzed to investigate the presence of right bundle branch block (RBBB) and crochetage R wave. RESULTS The ratio of crochetage R wave in inferior leads in patients with PFO was 45.3% and 21.2% without PFO. There were 17 (6.4%) patients with coexistence of crochetage R wave and RBBB, including 13 (6.5%) patients with PFO and four (6.1%) patients without PFO. The accuracies of TTE, crochetage R wave, and RBBB were 0.637, 0.535, and 0.314, respectively. A combination of crochetage R wave and RBBB demonstrated a sensitivity of 0.507 and a specificity of 0.758. When TTE, crochetage R wave, and RBBB were combined, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 0.712, 0.801, 0.439, 0.813, and 0.420, respectively. Logistic regression analysis revealed a correlation between PFO and the presence of crochetage R wave (odds ratio [OR]: 3.073, 95% confidence interval [CI]: 1.601-5.899, p < 0.001), and also a combination between crochetage R wave and RBBB (OR: 3.220, 95% CI: 1.720-6.028, p < 0.001). CONCLUSIONS Crochetage R wave in ECG was associated with PFO. Crochetage R wave, especially combined with RBBB and TTE, may be helpful in the early detection of patients with PFO.
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Affiliation(s)
- Peng Jin
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
| | - Piqi Jiao
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
| | - Juan Feng
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
| | - Liang Shi
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
| | - Ling Ma
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
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29
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Kawamura I, Batul SA, Vijayaraman P, Needelman B, Choy A, Martinez J, Tung R, Khera S, Kini A, Sharma S, Reddy VY, Koruth JS. ECG characteristics of "true" left bundle branch block: Insights from transcatheter aortic valve-related LBBB and His-Purkinje conduction system pacing-correctable LBBB. Heart Rhythm 2023; 20:1659-1666. [PMID: 37696443 DOI: 10.1016/j.hrthm.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Left bundle branch block (LBBB) pattern on the electrocardiogram includes patients with both complete conduction block in the His-Purkinje system as well as nonspecific left ventricular conduction delay without discrete block. OBJECTIVE The purpose of this study was to characterize electrocardiographic morphological features of LBBB patterns in patients with (1) LBBB after transcatheter aortic valve replacement (TAVR) and (2) LBBB correctable by conduction system pacing (CSP). METHODS Consecutive patients with post-TAVR (n = 123) or CSP-correctable LBBB (n = 58) from 2 centers were included in this retrospective evaluation. QRS durations as well as detailed morphological features, including notching and slurring, of QRS complexes in leads I, aVL, V1, V2, V5, and V6 and in all 3 inferior leads were recorded. RESULTS The mean age of the entire cohort was 78.3 ± 10.1 years, with 48% of the cohort being male (87/181). In the CSP-correctable group (n = 58), 14 (24.1%) underwent His-bundle pacing and 44 (75.9%) left bundle branch area pacing. A total of 17 of 181 (9.4%) of the combined cohort failed to completely meet the Strauss criteria. QRS morphology in lead V1/V2 was always either rS or QS, and there were no q/Q waves noted in lead V5/V6. Although dominant R waves were seen in leads I and aVL of 176 of 181 (97.2%), q/Q waves were present in only 21 of 181 (11.6%). Importantly, notched or slurred QRS complexes were identified in at least 1 lead of 4 leads I, aVL, V5, and V6 in 181 of 181 (100%). CONCLUSION Strauss criteria and QRS notching are highly prevalent in LBBB after TAVR and in LBBB correctable by CSP.
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Affiliation(s)
- Iwanari Kawamura
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Syeda Atiqa Batul
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
| | - Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
| | - Brandon Needelman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alex Choy
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jake Martinez
- The University of Arizona College of Medicine, Banner-University Medical Center, Phoenix, Arizona
| | - Roderick Tung
- The University of Arizona College of Medicine, Banner-University Medical Center, Phoenix, Arizona
| | - Sahil Khera
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
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30
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Tereshchenko LG. In search of the "true" left bundle branch block: The art of asking research questions. Heart Rhythm 2023; 20:1667-1668. [PMID: 37741526 DOI: 10.1016/j.hrthm.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 09/25/2023]
Affiliation(s)
- Larisa G Tereshchenko
- Department of Quantitative Health Sciences, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland, Ohio.
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Pérez-Riera AR, Barbosa-Barros R, Andreou AY, Fiol-Sala M, Birnbaum Y, da Silva Rocha M, Daminello-Raimundo R, de Abreu LC, Nikus K. Left septal fascicular block: Evidence, causes, and diagnostic criteria. Heart Rhythm 2023; 20:1558-1569. [PMID: 37586583 DOI: 10.1016/j.hrthm.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
The existence of a tetrafascicular intraventricular conduction system is widely accepted by researchers. In this review, we have updated the criteria for left septal fascicular block (LSFB) and the differential diagnosis of prominent anterior QRS forces. More and more evidence points to the fact that the main cause of LSFB is critical proximal stenosis of the left anterior descending coronary artery before its first septal perforator branch. The most important characteristic of LSFB that has been incorporated in the corresponding diagnostic electrocardiographic criteria is its transient/intermittent nature mostly observed in clinical scenarios of acute (ie, acute coronary syndrome including vasospastic angina) or chronic (ie, exercise-induced ischemia) ischemic coronary artery disease. In addition, the phenomenon proved to be phase 4 bradycardia rate dependent and induced by early atrial extrastimulus. Finally, we believe that intermittent LSFB has the same clinical significance as "Wellens syndrome" and the "de Winter pattern" in the acute coronary syndrome scenario.
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Affiliation(s)
- Andrés Ricardo Pérez-Riera
- Laboratório de Metodologia de Pesquisa e Escrita Científica, Centro Universitário Saúde ABC, Santo André, São Paulo, Brazil; Clínica Médica, Universidade Uninove, Mauá, São Paulo, Brazil.
| | - Raimundo Barbosa-Barros
- Coronary Center of the Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Andreas Y Andreou
- Department of Cardiology, Limassol General Hospital, Limassol, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus
| | - Miguel Fiol-Sala
- Balearic Islands Institute for Health Research, Hospital Son Espases, Palma de Mallorca, Spain
| | - Yochai Birnbaum
- Department of Medicine Cardiology, Baylor College of Medicine, Houston, Texas
| | | | - Rodrigo Daminello-Raimundo
- Laboratório de Metodologia de Pesquisa e Escrita Científica, Centro Universitário Saúde ABC, Santo André, São Paulo, Brazil
| | - Luiz Carlos de Abreu
- Laboratório de Metodologia de Pesquisa e Escrita Científica, Centro Universitário Saúde ABC, Santo André, São Paulo, Brazil; Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Kjell Nikus
- Heart Center, Tampere University Hospital, Tampere, Finland; Faculty of Medicine, Tampere University, Tampere, Finland
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Obregón-Rosas S, Montañez-Aguirre ÁA, Sotelo-Lozano MT, Ortega-Cerda JJ. Right fascicular blocks: A case series and a comprehensive electrocardiographic analysis. J Electrocardiol 2023; 81:159-162. [PMID: 37738713 DOI: 10.1016/j.jelectrocard.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023]
Abstract
The main trunk of the right bundle branch divides into an anterior, middle (lateral) and posterior fascicle. This article describes the right anterior and posterior fascicular block. They present a diagnostic challenge and are often overlooked during diagnostic processes. The studied patients were young adults whose electrocardiographic tracings were registered at the Mexican Faculty of Medicine of La Salle University. The presence of delayed R-peak time in aVR and V1, along with the described ventricular complex morphologies, and a right or left deviation of the cardiac axis exceeding +60°, may be suggestive of right fascicular blocks.
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Affiliation(s)
- Santiago Obregón-Rosas
- Mexican Faculty of Medicine of La Salle University, Las Fuentes 17, Tlalpan Centro I, Tlalpan, Mexico City, 01400, Mexico.
| | - Ángel Antonio Montañez-Aguirre
- Mexican Faculty of Medicine of La Salle University, Las Fuentes 17, Tlalpan Centro I, Tlalpan, Mexico City, 01400, Mexico.
| | - María Teresa Sotelo-Lozano
- Mexican Faculty of Medicine of La Salle University, Las Fuentes 17, Tlalpan Centro I, Tlalpan, Mexico City, 01400, Mexico.
| | - José Juan Ortega-Cerda
- La Salle University Mexican Faculty of Medicine, Professor Emeritus, Las Fuentes 17, Tlalpan Centro I, Tlalpan, 14000 Ciudad de México, Mexico; Hospital Angeles Health System; Director of teaching and research. Camino Sta. Teresa 1055-S, Héroes de Padierna, La Magdalena Contreras, 10700 Ciudad de México, Mexico; Hospital Angeles Pedregal, La Magdalena Contreras, Mexico City, Mexico.
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Ali H, Lupo P, Foresti S, De Ambroggi G, Anderson RH, De Lucia C, Turturiello D, Paganini EM, Bessi R, Contrafatto I, Farghaly AAA, Cristiano E, Cappato R. Catheter-induced right bundle branch block: Practical implications for the cardiac electrophysiologist. J Cardiovasc Electrophysiol 2023; 34:2316-2329. [PMID: 37655997 DOI: 10.1111/jce.16050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/23/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
The right bundle branch (RBB), due to its endocardial course, is susceptible to traumatic block caused by "bumping" during right-heart catheterization. In the era of cardiac electrophysiology, catheter-induced RBB block (CI-RBBB) has become a common phenomenon observed during electrophysiological studies and catheter ablation procedures. While typically transient, it may persist for the entire procedure time. Compared to pre-existing RBBB, the transient nature of CI-RBBB allows for comparative analysis relative to the baseline rhythm. Furthermore, unlike functional RBBB, it occurs at similar heart rates, making the comparison of conduction intervals more reliable. While CI-RBBB can provide valuable diagnostic information in various conditions, it is often overlooked by cardiac electrophysiologists. Though it is usually a benign and self-limiting conduction defect, it may occasionally lead to diagnostic difficulties, pitfalls, or undesired consequences. Avoidance of CI-RBBB is advised in the presence of baseline complete left bundle branch block and when approaching arrhythmic substrates linked to the right His-Purkinje-System, such as fasciculo-ventricular pathways, bundle branch reentry, and right-Purkinje focal ventricular arrhythmias. This article aims to provide a comprehensive practical review of the electrophysiological phenomena related to CI-RBBB and its impact on the intrinsic conduction system and various arrhythmic substrates.
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Affiliation(s)
- Hussam Ali
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Pierpaolo Lupo
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Sara Foresti
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Guido De Ambroggi
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Carmine De Lucia
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Dario Turturiello
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Edoardo Maria Paganini
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Riccardo Bessi
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Igino Contrafatto
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
- Cardiac Electrophysiology, Salus Hospital, Reggio Emilia, Italy
| | - Ahmad Abdelrady Abdelsalam Farghaly
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
- Cardiovascular Department, Assiut University, Assiut, Egypt
| | - Ernesto Cristiano
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
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Benezet-Mazuecos J, Baranchuk A, Lozano Á, Crosa J, Miracle Á. Left bundle branch pacing in alternating bundle branch block. J Electrocardiol 2023; 81:250-252. [PMID: 37862914 DOI: 10.1016/j.jelectrocard.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/08/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
We present a case of symptomatic intermittent AV block showing during monitorization alternating bundle branch block. Presuming a high need of pacing, conduction system pacing was considered a more physiological alternative in this patient. Left bundle branch pacing restored a stable atrioventricular synchrony with a paced QRS complex similar to the native one and might be a good alternative in these cases.
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Affiliation(s)
- Juan Benezet-Mazuecos
- Arrhythmia Unit, Cardiology Department, Hospital Universitario La Luz, Madrid, Spain.
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Álvaro Lozano
- Arrhythmia Unit, Cardiology Department, Hospital Universitario La Luz, Madrid, Spain
| | - Julián Crosa
- Arrhythmia Unit, Cardiology Department, Hospital Universitario La Luz, Madrid, Spain
| | - Ángel Miracle
- Arrhythmia Unit, Cardiology Department, Hospital Universitario La Luz, Madrid, Spain
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Alboni P, Holzl A, Baggioni GF. Intermittent isolated anterior displacement of QRS complex - Differential diagnosis. J Electrocardiol 2023; 81:224-229. [PMID: 37837740 DOI: 10.1016/j.jelectrocard.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/26/2023] [Accepted: 10/01/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND The proposed criteria for diagnosis of left septal (middle) fascicular block (LSFB) appear to be conflicting. Moreover, it has been claimed that isolated anterior displacement (AD) of QRS complex could be a manifestation of a conduction delay of the right bundle branch, besides of LSFB. The purpose of the present study was to better define the etiology of AD through an analysis of the case reports dealing with intermittent AD, published up to now. METHODS PubMed search was performed to include all case reports dealing with intermittent AD occurring spontaneously, with an available 12‑lead electrocardiographic recording. Pertinent data were extracted from the papers for further analysis. RESULTS Eighteen case reports were found in the literature; in all cases intermittent AD was attributed to LSFB. In all cases AD was associated to changes of initial QRS forces, characterized by disappearance of septal q waves (in I and V6) and/or appearance of a small q wave in leads V1-V3. Morphology of terminal QRS forces, analysed for the first time, was unchanged in 90% of cases. Some Isolated ADs observed during induction of premature atrial extra-stimuli and recorded by vectorcardiographic tracing and some electrocardiographic leads were attributed to a conduction delay of the right bundle branch. In this case, initial QRS forces did not change and terminal QRS forces shifted to the right. CONCLUSIONS In the presence of intermittent isolated AD, a differential diagnosis between LSFB and a conduction delay of the right bundle branch appears to be possible by the analysis of initial and terminal QRS forces. Instead, the diagnosis of permanent LSFB remains a challenge.
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Affiliation(s)
- Paolo Alboni
- Section of Cardiology, Quisisana Private Hospital, Ferrara, Italy.
| | - Anna Holzl
- Section of Cardiology, Quisisana Private Hospital, Ferrara, Italy
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Kawji MM. Alternating right and left bundle branch block during a treadmill stress test. J Electrocardiol 2023; 81:1-3. [PMID: 37453272 DOI: 10.1016/j.jelectrocard.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/12/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Mazen M Kawji
- OSF Cardiovascular Institute, Peoria, IL, United States of America; Saint Elizabeth Medical Center, Ottawa, IL, United States of America.
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Ye Y, Chen X, He L, Wu S, Su L, He J, Zhang Y, Sheng X, Yu C, Yang Y, Wang B, Huang Z, Su Y, Huang W, Fu G. Left Bundle Branch Pacing for Heart Failure and Left Bundle Branch Block Patients With Mildly Reduced and Preserved Left Ventricular Ejection Fraction. Can J Cardiol 2023; 39:1598-1607. [PMID: 37714328 DOI: 10.1016/j.cjca.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Left bundle branch block (LBBB) may induce or aggravate heart failure (HF). Few data are available on patients with HF and LBBB with mildly reduced ejection fraction (HFmrEF; left ventricular ejection fraction [LVEF] 40%-50%) and those with preserved EF (HFpEF. LVEF ≥ 50%). We aimed to assess the long-term outcomes of left bundle branch pacing (LBBP) on cardiac function and remodelling in patients with LBBB and symptomatic HFmrEF and HFpEF. METHODS Nonischemic cardiomyopathy (NICM) patients with HFmrEF and HFpEF (LVEF from 40% to 60% as defined with the use of echocardiography) with LBBB who successfully underwent LBBP (n = 50) were prospectively included from 4 centres. Patient characteristics and echocardiographic and lead parameters were recorded at implantation and during follow-ups of 1, 3, 6, and 12 months. RESULTS All patients completed 1-year follow up. The LVEF was significantly improved from 46.5 ± 5.2% at baseline to 60.0 ± 6.1% (n = 50; P < 0.001) after 1-year follow up. Higher ΔLVEF and super-response rate were observed in the HFmrEF group (n = 30) than in the HFpEF group (n = 20). CONCLUSIONS LBBP improved symptoms and reversed remodelling in patients with LBBB and symptomatic HF at 1-year follow-up. Improvement occurred even in HFpEF patients, and the resynchronisation effect was better in HFmrEF group.
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Affiliation(s)
- Yang Ye
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Xueying Chen
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lang He
- Department of Cardiology, Zhejiang Greentown Cardiovascular Hospital, Hangzhou, Zhejiang, China
| | - Shengjie Wu
- Department of Cardiology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Key Laboratory of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Lan Su
- Department of Cardiology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Key Laboratory of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Jialin He
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yu Zhang
- Department of Nuclear Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Chan Yu
- Department of Cardiac Echocardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Yang
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Bei Wang
- Department of Cardiac Echocardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhongke Huang
- Department of Nuclear Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yangang Su
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weijian Huang
- Department of Cardiology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Key Laboratory of Cardiovascular Disease of Wenzhou, Wenzhou, China.
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, Zhejiang, China.
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Falcão AM, Suares VL, Chalela WA. Left Anterior Fascicular Block Associated with Atrioventricular Block during Exercise Stress Test. Arq Bras Cardiol 2023; 120:e20230200. [PMID: 37991121 DOI: 10.36660/abc.20230200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/16/2023] [Indexed: 11/23/2023] Open
Affiliation(s)
- Andréa Marinho Falcão
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Vagner L Suares
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - William A Chalela
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
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Lee SH, Choi J, Park S, Park K, Kim JS, On YK. Association of right bundle branch block or intraventricular conduction delay with recurrence of atrial fibrillation after catheter ablation. Ann Noninvasive Electrocardiol 2023; 28:e13083. [PMID: 37691230 PMCID: PMC10646381 DOI: 10.1111/anec.13083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND The association between bundle branch block (BBB) and recurrence of atrial fibrillation (AF) after catheter ablation is unclear. The aim of this study was to determine whether AF combined with BBB is associated with AF recurrence after catheter ablation. METHODS A total of 477 consecutive AF patients who underwent catheter ablation were included. The AF patients were divided into three groups according to BBB: AF without BBB (n = 427), AF with right bundle branch block (AF with RBBB) (n = 16), and AF with intraventricular conduction delay (AF with IVCD) (n = 34). RESULTS Of the 477 AF patients (mean age 57 years, 81% men, median CHA2 DS2 -VASc score of 1), 16 (3.4%) patients had RBBB, and 34 (7.1%) patients had IVCD. During a mean follow-up of 15.2 ± 6.7 months, 119 patients (24.9%) had recurrence of AF. Of these, 111 (26%) patients were in the AF without BBB group, with 2 (12.5%) and 6 (17.6%) patients in the RBBB and IVCD groups, respectively. The Kaplan-Meier estimate of the rate of recurrent AF was not significantly different among the three groups (p = .39). Multivariable analysis showed that persistent AF (HR 1.7, 95% CI 1.15-2.50, p = .007), chronic kidney disease (HR 2.94, 95% CI 1.20-7.17, p = .01), and left atrial diameter (HR 1.04, 95% CI 1.009-1.082, p = .01) were significantly associated with AF recurrence. CONCLUSION AF with BBB was not significantly associated with the recurrence of AF after catheter ablation in middle-aged patients with low-risk cardiovascular profile.
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Affiliation(s)
- Sung Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung HospitalSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Ji‐Hoon Choi
- Division of Cardiology, Department of Internal MedicineKonkuk University Medical Center, Konkuk University School of MedicineSeoulRepublic of Korea
| | - Seung‐Jung Park
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Kyoung‐Min Park
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - June Soo Kim
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Young Keun On
- Division of CardiologyDepartment of MedicineHeart Vascular and Stroke InstituteSamsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
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Asmarats L, Gutiérrez-Alonso L, Nombela-Franco L, Regueiro A, Millán X, Tirado-Conte G, Cepas P, Li CHP, Fernández-Peregrina E, Jiménez-Quevedo P, Freixa X, Arzamendi D. Cusp-overlap technique during TAVI using the self-expanding Portico FlexNav system. Rev Esp Cardiol (Engl Ed) 2023; 76:767-773. [PMID: 36804557 DOI: 10.1016/j.rec.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/07/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION AND OBJECTIVES The cusp overlap technique (COT) has been proposed to reduce conduction disturbances (CD) after transcatheter aortic valve implantation (TAVI) with self-expanding supra-annular devices, but there are scarce data on COT with intra-annular valves. The aim of this study was to determine whether the use of the COT during Portico implantation results in higher valve implantation and lower rates of CD. METHODS We included 85 patients undergoing TAVI with the Portico FlexNav system: 43 retrospective patients using the standard 3-cusp view and 42 prospective patients with the COT. Primary endpoints were implantation depth and new-onset CD (composite outcome of new-onset left bundle branch block and new permanent pacemaker implantation). RESULTS COT resulted in a higher implantation depth (noncoronary cusp: 4.9±3.9 vs 7.4±3.0; P=.005) and lower new-onset CD (31.0% vs 58.1%; P=.012), with a tendency toward a lower need for permanent pacemaker implantation (14.3% vs 30.2%, P=.078; 7.7% vs 31.0%; P=.011 in patients without pre-existing right bundle branch block). Transvalvular aortic gradients were slightly lower with COT (8.7±3.7 vs 11.0±6.1; P=.044). There were no differences in technical success or major procedure-related complications. On multivariate analysis, COT use was associated with a lower risk of new-onset CD. CONCLUSIONS Use of the COT during Portico implantation is feasible and facilitates a higher valve implant, which in turn may help to reduce rates of new-onset CD.
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Affiliation(s)
- Lluis Asmarats
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Lola Gutiérrez-Alonso
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Luis Nombela-Franco
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Ander Regueiro
- Servicio de Cardiología, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Xavier Millán
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Gabriela Tirado-Conte
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Pedro Cepas
- Servicio de Cardiología, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Chi Hion Pedro Li
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Estefanía Fernández-Peregrina
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Pilar Jiménez-Quevedo
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Xavier Freixa
- Servicio de Cardiología, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Dabit Arzamendi
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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Schlömicher M, Useini D, Haldenwang PL, Naraghi H, Moustafine V, Bechtel M, Strauch JT. Outcomes in Patients with Left Bundle Branch Block after Rapid Deployment Aortic Valve Replacement. Thorac Cardiovasc Surg 2023; 71:528-534. [PMID: 35108737 DOI: 10.1055/s-0042-1742361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Increased rates of postoperative left bundle branch block (LBBB) and permanent pacemaker implantation (PPI) frequently occur after implantation of rapid deployment valves. The impact of LBBB on follow-up outcomes remains controversial. So far, no data regarding long-term outcomes exist. AIM The aim of this study was to analyze the impact of LBBB on postoperative outcomes after rapid deployment aortic valve replacement (RDAVR). METHODS A total of 620 consecutive patients without preexisting LBBB or PPI who underwent rapid deployment AVR between March 2012 and September 2019 were included. New-onset LBBB was defined as any new LBBB that persisted at hospital discharge. The median follow-up time for clinical data was 1.7 years post-RDAVR. RESULTS At discharge, new-onset LBBB was seen in 109 patients (17.5%). There were no differences between the LBBB groups and no-LBBB groups regarding baseline characteristics. At a median follow-up of 1.7 years, no difference was found between LBBB groups and no-LBBB groups concerning all-cause mortality (12.8 vs. 11.7%; hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 0.74-1.53; p = 0.54). Nevertheless, new-onset LBBB was associated with significant higher pacemaker implantation rates at follow-up (10.1 vs. 6.3%; HR: 3.58; 95% CI: 1.89-6.81 p < 0.001). CONCLUSION After a median follow-up of 1.7 years, new-onset LBBB was not associated with increased mortality. Nevertheless, higher pacemaker implantation rates were observed in patients with new-onset LBBB after RDAVR.
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Affiliation(s)
- Markus Schlömicher
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Dritan Useini
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Peter Lukas Haldenwang
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Hamid Naraghi
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Vadim Moustafine
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Matthias Bechtel
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Justus Thomas Strauch
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
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Lakshman H, Banthiya S, Ahmed A, Shah D. An interesting case of infra-hisian block. Pacing Clin Electrophysiol 2023; 46:1182-1185. [PMID: 37650470 DOI: 10.1111/pace.14808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/27/2023] [Accepted: 08/15/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The management of patients with conduction disease and supraventricular arrhythmias presents a multitude of clinical challenges.Intra-Hisian block, a condition characterized by delayed or blocked electrical conduction within the His bundle, can result in debilitating symptoms, such as syncope or presyncope. This case report aims to elucidate the diagnostic and therapeutic considerations that were taken in a patient who presented with recurrent syncopal episodes that corresponded to atrial flutter (AFL) and subsequently underwent cavotricuspid isthmus ablation. CASE PRESENTATION A 65-year-old male with paroxysmal AFL and a pre-existing right bundle branch block and left anterior fascicular block (RBBB+LAFB) experienced recurrent syncopal episodes that were found to be correlated with AFL episodes. Following CTI ablation, an electrophysiology study (EPS) revealed a prolonged HV interval of 101ms, which indicated potential conduction abnormalities. With coronary sinus pacing, an intra-Hisian delay of 211ms was observed. During instances of atrioventricular block, intra-Hisian delay was evident on conducted beats, followed by intra-Hisian block on non-conducted beats. Ultimately, the patient's syncopal episodes prompted the placement of a dual-chamber pacemaker, which resulted in the resolution of symptoms. CONCLUSION Intra-Hisian block is a condition that is often associated with delayed or blocked electrical conduction within the His bundle. When symptomatic, patients often present with syncope or presyncope. Etiologies of this condition include degenerative changes, myocardial infarction, autoimmune disorders, infections, medications, and more. This case emphasizes the importance of electrophysiology studies (EPS) in the diagnosis and management of patients with intra-Hisian block. Prompt intervention, such as the placement of a dual-chamber pacemaker, can alleviate symptoms and improve patient outcomes. Thus, clinical awareness and utilization of EPS can aid in accurate diagnosis and appropriate treatment selection for patients with conduction abnormalities and supraventricular arrhythmias.cuspid isthmus (CTI) ablation.
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Affiliation(s)
- Harini Lakshman
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Sukriti Banthiya
- Department of Internal Medicine, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Ammar Ahmed
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Dipak Shah
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, Michigan, USA
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Zeng J, He C, Zou F, Qin C, Xue S, Zhu H, Li X, Liu Z, Wei Y, Hou S, Qian Z, Wang Y, Hou X, Yao Y, Ellenbogen KA, Fan X, Zou J. Early left bundle branch pacing in heart failure with mildly reduced ejection fraction and left bundle branch block. Heart Rhythm 2023; 20:1436-1444. [PMID: 37495037 DOI: 10.1016/j.hrthm.2023.07.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Left bundle branch pacing (LBBP) achieves resynchrony and improves cardiac function in heart failure (HF) patients with reduced ejection fraction (EF) by correcting left bundle branch block (LBBB). Few data on the efficacy of early LBBP in HF with mildly reduced EF (HFmrEF) and LBBB have been reported. OBJECTIVE The purpose of this study was to explore the efficacy of early LBBP in patients with HFmrEF and LBBB. METHODS Consecutive patients with HFmrEF (left ventricular EF [LVEF] 35%-50%) and LBBB were prospectively enrolled to receive LBBP (Early-LBBP group) plus guideline-directed medical therapy (GDMT) or GDMT alone (GDMT group). Study outcomes included changes in LVEF, LV end-diastolic diameter (LVEDD), New York Heart Association (NYHA) functional classification, and N-terminal pro-brain natriuretic peptide (NT-proBNP), and clinical events (HF rehospitalization or syncope). Subgroup analysis compared efficacy of LBBP between patients with LBBB only without comorbidities or late gadolinium enhancement (LGE) (LBBB-Only group) and patients with either comorbidities or LGE (LBBB-Combined group). RESULTS Fifty-four patients were enrolled and analyzed (37 Early-LBBP group; 15 GDMT group). LBBP achieved greater improvement in LVEF (+14.75% ± 7.37% vs -2.42% ± 2.84%; P <.001), reduction of LVEDD (-7.51 ± 5.40 mm vs -0.87 ± 4.36 mm; P <.001) and NYHA classification (-0.84 ± 0.76 vs -0.13 ± 0.74; P = .004), and similar reduction of NT-proBNP (-408.83 ± 920.29 pg/mL vs -229.05 ± 1579.17 pg/mL; P = .610) at 6 months. Early LBBP showed significantly reduced clinical events (0.0% vs 40.0%; P <.001) after 20.68 ± 13.55 months of follow-up. Subgroup analysis showed patients in the LBBB-Only group benefited more from LBBP with regard to LVEF improvement and LVEDD reduction than the LBBB-Combined group. CONCLUSION Early LBBP with GDMT demonstrated greater improvement of cardiac function and reduced clinical events than GDMT alone in patients with HFmrEF and LBBB.
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Affiliation(s)
- Jiaxin Zeng
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Chen He
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | - Chaotong Qin
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Siyuan Xue
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Haojie Zhu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaofei Li
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhimin Liu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongyue Wei
- Center for Public Health and Epidemic Preparedness & Response, Peking University, Beijing, China
| | - Shuyan Hou
- Nanjing Foreign Language School, Nanjing, China
| | - Zhiyong Qian
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yao Wang
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaofeng Hou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yan Yao
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | - Xiaohan Fan
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jiangang Zou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China; Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China.
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Wang L, Lu YW, Zhao YT. Chest Pain With Exercise-Induced Left Bundle-Branch Block-Is There a Connection? JAMA Intern Med 2023; 183:1160-1161. [PMID: 37639241 DOI: 10.1001/jamainternmed.2023.2264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
This case report describes a patient in their early 60s with chest pain during exertion.
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Affiliation(s)
- Lei Wang
- Department of Cardiology, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing 100049, China
| | - Yi-Wei Lu
- Department of Cardiology, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing 100049, China
| | - Yun-Tao Zhao
- Department of Cardiology, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, Beijing 100049, China
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Epstein R, Liberman L, Silver ES. Long-Term Follow-Up of Second-Degree Heart Block in Children. Pediatr Cardiol 2023; 44:1529-1535. [PMID: 37658175 DOI: 10.1007/s00246-023-03195-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/20/2023] [Indexed: 09/03/2023]
Abstract
Little is known about the outcomes of children with second-degree heart block. We aimed to determine whether children with structurally normal hearts and Mobitz 1, 2:1 block or Mobitz 2 are at increased risk for progressing to complete heart block (CHB) or requiring a pacemaker (PM) at long-term follow-up. We searched our institutional electrophysiology database for children with potentially concerning second-degree block on ambulatory rhythm monitoring between 2009 and 2021, defined as frequent episodes of Mobitz 1 or 2:1 block, episodes of Mobitz 1 or 2:1 block with additional evidence of conduction disease (i.e. first-degree heart block, bundle branch block), or episodes of Mobitz 2. Ambulatory rhythm monitor, ECG, and demographic data were reviewed. The primary composite outcome was CHB on follow-up rhythm monitor or PM placement. 20 patients were in the final analysis. Six (30%) patients either developed CHB but do not have a PM (4 = 20%) or have a PM (2 = 10%). Median follow-up was 5.8 years (IQR 4.4-7.0). Patients with CHB or PM were more likely to have second-degree block at maximum sinus rate (67% vs. 0%, p = 0.003), a below normal average heart rate (67% vs. 14%, p = 0.04), and 2:1 block on initial ECG (50% vs. 0%, p = 0.02). In this study of children with potentially concerning second-degree block, 30% of patients progressed to CHB or required a PM. Second-degree block at maximum sinus rate, a low average heart, and 2:1 block on initial ECG were associated with increased risk of disease progression.
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Affiliation(s)
- Rebecca Epstein
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, 3959 Broadway, New York, NY, 10032, USA.
| | - Leonardo Liberman
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, 3959 Broadway, New York, NY, 10032, USA
| | - Eric S Silver
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, 3959 Broadway, New York, NY, 10032, USA
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DeBauge A, Fairbank T, Harvey CJ, Ranka S, Jiwani S, Sheldon SH, Reddy M, Beaver TA, Noheria A. Electrocardiographic prediction of left ventricular hypertrophy in women and men with left bundle branch block - Comparison of QRS duration, amplitude and voltage-time-integral. J Electrocardiol 2023; 80:34-39. [PMID: 37178633 PMCID: PMC10846562 DOI: 10.1016/j.jelectrocard.2023.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Standard ECG criteria for left ventricular (LV) hypertrophy rely on QRS amplitudes. However, in the setting of left bundle branch block (LBBB), ECG correlates of LV hypertrophy are not well established. We sought to evaluate quantitative ECG predictors of LV hypertrophy in the presence of LBBB. METHODS We included adult patients with typical LBBB having ECG and transthoracic echocardiogram performed within 3 months of each other in 2010-2020. Orthogonal X, Y, Z leads were reconstructed from digital 12‑lead ECGs using Kors's matrix. In addition to QRS duration, we evaluated QRS amplitudes and voltage-time-integrals (VTIs) from all 12 leads, X, Y, Z leads and 3D (root-mean-squared) ECG. We used age, sex and BSA-adjusted linear regressions to predict echocardiographic LV calculations (mass, end-diastolic and end-systolic volumes, ejection fraction) from ECG, and separately generated ROC curves for predicting echocardiographic abnormalities. RESULTS We included 413 patients (53% women, age 73 ± 12 years). All 4 echocardiographic LV calculations were most strongly correlated with QRS duration (all p < 0.00001). In women, QRS duration ≥ 150 ms had sensitivity/specificity 56.3%/64.4% for increased LV mass and 62.7%/67.8% for increased LV end-diastolic volume. In men, QRS duration ≥ 160 ms had a sensitivity/specificity 63.1%/72.1% for increased LV mass and 58.3%/74.5% for increased LV end-diastolic volume. QRS duration was best able to discriminate eccentric hypertrophy (area under ROC curve 0.701) and increased LV end-diastolic volume (0.681). CONCLUSIONS In patients with LBBB, QRS duration (≥ 150 in women and ≥ 160 in men) is a superior predictor of LV remodeling esp. eccentric hypertrophy and dilation.
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Affiliation(s)
- Ashley DeBauge
- The University of Kansas School of Medicine, Kansas City, KS, United States of America
| | - Tyan Fairbank
- The University of Kansas School of Medicine, Kansas City, KS, United States of America
| | - Christopher J Harvey
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Sagar Ranka
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Sania Jiwani
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Seth H Sheldon
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Madhu Reddy
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Timothy A Beaver
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Amit Noheria
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, KS, United States of America.
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Shojaeefard E, Dehghani P, Akbari-Khezrabadi A, Naseri A, Salimi M, Hosseinpour M, Sarejloo S, Abdipour Mehrian SR, Karimi M, Bazrafshan Drissi H. Terminal T-wave concordance is associated with SYNTAX score among left bundle branch block patients suspected of acute coronary syndrome without modified Sgarbossa criteria. J Electrocardiol 2023; 80:178-182. [PMID: 37714665 DOI: 10.1016/j.jelectrocard.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Timely and precise diagnosis of ischemic cardiac events based on electrocardiogram is challengeable among patients with Left Bundle Branch Block (LBBB). The present study aimed to assess the correlation between SYNTAX score and terminal T-wave morphologies among LBBB patients suspected of Acute Coronary Syndrome (ACS) without modified Sgarbossa criteria. METHOD This cross-sectional study was conducted on the LBBB patients suspected of ACS without modified Sgarbossa criteria. Binary logistic regression was used to assess the correlation of ischemic heart disease (IHD, SYNTAX score > 0) and SYNTAX score categories with terminal T-wave morphologies including T-wave direction in lead V6 and terminal T-wave concordance in leads I, V5, and V6. RESULT This study was done on 93 patients with the mean age of 62.4 ± 9.6 years. More than half of the patients were female (58.1%, 95% CI: 47.4% to 68.2%). Among the participants with IHD, the SYNTAX score categories were correlated to discordant terminal T-wave in leads I, V5, and V6 (OR = 5.71, 95% CI: 1.04 to 31.28, p = 0.04). CONCLUSION Among the LBBB patients with acute ischemic cardiac events without modified Sgarbossa criteria, those with discordant terminal T-waves in leads I, V5, or V6 had higher SYNTAX scores and might require more invasive coronary revascularization techniques such as Coronary Artery Bypass Graft (CABG) surgery.
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Affiliation(s)
- Ehsan Shojaeefard
- Medical Doctor - Master of Public Health (MPH), School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pooyan Dehghani
- Interventional Cardiologist, Shiraz Research Center, Shiraz, Iran
| | - Ali Akbari-Khezrabadi
- Medical Doctor, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arzhang Naseri
- Medical Doctor, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Salimi
- Medical Doctor, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Morteza Hosseinpour
- Medical Doctor, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shirin Sarejloo
- Cardiologist, Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Reza Abdipour Mehrian
- Medical Doctor - Master of Public Health (MPH), School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammadreza Karimi
- Medical Doctor, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Bazrafshan Drissi
- Cardiologist, Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Assistant Professor of Cardiology, Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Rajjoub K, Vila-Olives R, Francisco-Pascual J. A wobble tachycardia… supraventricular, ventricular or both? J Electrocardiol 2023; 80:174-177. [PMID: 37562269 DOI: 10.1016/j.jelectrocard.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/11/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023]
Abstract
We present the case of a 77-year-old man with ischemic heart disease and baseline right bundle branch block having a well-tolerated and regular wide complex tachycardia with right bundle branch block morphology. A wide complex tachycardia (WCT) could be of supraventricular or ventricular origin. In this setting, we discuss the differential diagnosis of WCT, the usefulness and limitations of the diagnostic criteria for ventricular tachycardia.
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Affiliation(s)
- Kinán Rajjoub
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron i Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| | - Rosa Vila-Olives
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron i Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Jaume Francisco-Pascual
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron i Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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Maloof A, Triska J, Assaf Y, Birnbaum Y. Interpreting the ECG in patients with chest pain and right bundle branch block: A case report. J Electrocardiol 2023; 80:151-154. [PMID: 37390587 DOI: 10.1016/j.jelectrocard.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 07/02/2023]
Abstract
A patient with right bundle branch block (RBBB) presented with chest pain. An ECG showed ST-elevation in leads V1, V2, and aVR, with widespread ST-depression in leads II, aVF, I, aVL, and V4-6. The initial ECG interpretation missed ST-elevation myocardial infarction (STEMI), as ST-elevation thresholds were not reached. Non-urgent angiography showed severe left anterior descending artery stenosis requiring percutaneous coronary intervention. The course was complicated by cardiac arrest necessitating resuscitation and dual chamber pacemaker placement with left bundle branch pacing. This case report outlines the deficiencies of the current voltage criteria for identification of anterior STEMI in patients with RBBB.
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Affiliation(s)
- Alexandra Maloof
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Jeffrey Triska
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yazan Assaf
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
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Ogano M, Iwasaki YK, Okada T, Tanabe J, Shimizu W, Asai K. Preferred left ventricular lead position for upgrade from right ventricular pacing to cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2023; 34:1925-1932. [PMID: 37449446 DOI: 10.1111/jce.16005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) is well-established for treating symptomatic heart failure with electrical dyssynchrony. The left ventricular (LV) lead position is recommended at LV posterolateral to lateral sites in patients with left bundle branch block; however, its preferred region remains unclear in patients being upgraded from right ventricular (RV) apical pacing to CRT. This study aimed to identify the preferred LV lead position for upgrading conventional RV apical pacing to CRT. METHODS We used electrode catheters positioned at the RV apex and LV anterolateral and posterolateral sites via the coronary sinus (CS) branches to measure the ratio of activation time to QRS duration from the RV apex to the LV anterolateral and posterolateral sites during RV apical pacing. Simultaneous biventricular pacing was performed at the RV apex and each LV site, and the differences in QRS duration and LV dP/dtmax from those of RV apical pacing were measured. RESULTS Thirty-seven patients with anterolateral and posterolateral LV CS branches were included. During RV apical pacing, the average ratio of activation time to QRS duration was higher at the LV anterolateral site than at the LV posterolateral site (0.90 ± 0.06 vs. 0.71 ± 0.11, p < .001). The decreasing ratio of QRS duration and the increasing ratio of LV dP/dtmax were higher at the LV anterolateral site than at the posterolateral site (45.7 ± 18.0% vs. 32.0 ± 17.6%, p < .001; 12.7 ± 2.9% vs. 3.7 ± 8.2%, p < .001, respectively) during biventricular pacing compared with RV apical pacing. CONCLUSION The LV anterolateral site is the preferred LV lead position in patients being upgraded from conventional RV apical pacing to CRT.
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Affiliation(s)
- Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center, Shimizu, Sunto Shizuoka, Japan
| | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School, Bunkyo, Tokyo, Japan
| | - Taiji Okada
- Department of Cardiovascular Medicine, Shizuoka Medical Center, Shimizu, Sunto Shizuoka, Japan
| | - Jun Tanabe
- Department of Cardiovascular Medicine, Shizuoka Medical Center, Shimizu, Sunto Shizuoka, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Bunkyo, Tokyo, Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School, Bunkyo, Tokyo, Japan
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