Hereditary bundle branch system defect. A new genetic entity?

Sudden death in an adult with a small ventricular septal defect and an aneurysmal membranous septum

An apparently healthy man of 26 years of age suddenly died. He was known to have had a small ventricular septal defect and complete right bundle branch block from early childhood. At post-mortem examination the small ventricular septal defect was found associated with an aneurysm of the membranous septum. Histological examination showed a normal atrioventricular node and bundle, adjacent to the aneurysm. There was fibrous interruption at the commencement of the right bundle branch, which was considered the basis of the bundle branch block. It was also considered that the right bundle branch block was of the hereditary type and that this, rather than the aneurysm of the membranous septum, was responsible for the unexpected death.

Hereditary bundle branch defect: right bundle branch blocks of different causes have different morphologic characteristics

Hereditary bundle branch defect is an autosomal dominant genetic disease that, in a large Lebanese family, was mapped to the long arm of chromosome 19. Affected individuals have various combinations of conduction defects such as right bundle branch block, left or right QRS frontal-axis deviation, or atrioventricular blocks. We now further characterize this disease with the presentation of a two-decade follow-up and analysis of electrocardiographic features and mutation-carrier status. The conduction block may be overt in the first year of life, and among affected individuals, there is a worsening of the conduction block in 5% to 15% of cases, leading to complete atrioventricular block and possibly to sudden death. A group of individuals had QRS anomalies in right precordial leads such as rsr's', rss', or rSr', which may account for partial right bundle branch blocks. In this group, which we referred to as having an "r' pattern," 53% were actually mutation carriers, and 19% evolved toward a complete fascicular block. By contrast, mutation carriers with a normal electrocardiogram remained normal. The QRS morphologic appearance in the right precordial leads of affected individuals and r' pattern mutation carriers is notable for the absence or weakness of negative forces resulting in a rsR' or rR' morphology. In addition, an r' pattern is highly suggestive of a mutation carrier status in the presence of a broad r wave in aVR and s in V6 or a frontal-axis deviation. Finally, mutation carriers demonstrate a conduction block significantly more often in males than females (75% and 50%, respectively). This incomplete penetrance and slow evolution suggest that the actual prevalence of hereditary bundle branch defect is very much underestimated.

An isolated cardiac conduction disease maps to chromosome 19q

Isolated cardiac conduction disease is an autosomal dominant defect that includes various combinations of bundle branch or fascicular blocks. These defects can cause sudden death due to a complete heart block. We used a genome-wide screening approach with polymorphic (CA)n repeat markers to determine the chromosomal position of the gene defect implicated in this disorder. The analyses were carried out on a large Lebanese kindred, which included individuals with either a complete or incomplete right bundle branch block (RBBB) with a vertical-axis deviation (< or = -30 or > or = +100). Linkage to the disease locus was detected with the polymorphic marker D19S604 on the q arm of chromosome 19 (19q13.3) with a multipoint lod score of 7.18. Additionally, we were able to exclude the flanking loci D19S606 and D19S571, which are 13 cM apart because of recombination events in three affected individuals. The histidine-rich calcium-binding protein gene is found in this region and is an attractive candidate gene on the basis of its physiological properties and a tight linkage. There is no expansion in two exon 1 regions known for a variable number of triplet repeats.

Prevalence of intraventricular block in the general population: the Framingham Study

QRS intervals in the ECGs of members of the Framingham Heart Study cohort and offspring were measured to provide an estimate of the prevalence of intraventricular block in the general population. Intervals of greater than or equal to 0.09 second appear in men twice as commonly as in women, are rare before age 50 to 60, and shift from a predominance of right bundle branch block in the young to an indeterminate pattern in the elderly. Complete intraventricular block (QRS interval greater than or equal to 0.12 second) is seen in 11% of elderly men and 5% of elderly women. Aside from age and sex, logistic regression indicates strong associations with concurrent manifestations of coronary heart disease, congestive heart failure, and atrioventricular block, as well as hypertension, left ventricular hypertrophy, and ventricular extrasystoles. Among those subjects free of clinical coronary disease and congestive heart failure, associations between QRS interval and age, sex, atrioventricular block, and ECG left ventricular hypertrophy remain significant by multivariate analysis. Whether people with prolonged QRS intervals need special monitoring or attention cannot be told from these data.