Abnormal septal motion in patients with postoperative right bundle branch block pattern

Left bundle branch area pacing improves right ventricular function and synchrony

BACKGROUND

The impact of left bundle branch area pacing (LBBAP) on right ventricular (RV) function and tricuspid regurgitation (TR) remains unclear.

OBJECTIVE

We aimed to assess the long-term effects of LBBAP on RV performance and on TR.

METHODS

RV function was evaluated using RV free wall strain, tricuspid annular plane systolic excursion, fractional area changing, and systolic velocity of the lateral tricuspid annulus. The presence of reverse septal flash (RSF) and basal bulge (BB) was used to assess RV motion pattern. The distance between the lead entry site on the interventricular septum and the septal leaflet of the tricuspid annulus (lead-TV distance) was measured.

RESULTS

The analysis included 122 subjects [62 men (50.8%); mean age 76.5 ± 11.4 years] with a median follow-up of 21 months (18-24.5 months). During follow-up, RV free wall strain improved significantly (15.2 ± 5.8 vs 16.4 ± 5.5; P < .001) while tricuspid annular plane systolic excursion, systolic, and fractional area changing remained unchanged. Left ventricular ejection fraction was an independent predictor of improved RV function (B = 3.51; 95% confidence interval 1.39-8.9; P = .01). With LBBAP, RSF disappeared in 22 of 23 patients (96%) and BB in 15 of 22 patients (68%) in whom RSF and BB were present at baseline, respectively. RV function improvement was significantly higher when RSF was present at baseline (14 patients vs 11 patients; P = .02). At follow-up, no significant deterioration in TR occurred for the overall group. However, a lead-TV distance of <24.5 mm was associated with TR progression.

CONCLUSION

LBBAP has a favorable impact on RV function. A basal LBBAP position is associated with worsening TR.

Cardiac MRI of characteristic motion findings in right bundle branch block

While there have been many descriptions of characteristic motion findings in left bundle branch block (LBBB), there are few published descriptions of such findings in right bundle branch block (RBBB). The purpose of this study was to assess the frequency of particular regional motion findings in cardiac magnetic resonance imaging (CMR) studies of patients with RBBB, compared with normal subjects. We focused on three distinctive motion patterns that can be seen in RBBB during early systole: delayed apex-ward motion of the RV base, "reverse septal flash", and "basal bulge". The presence and relative magnitude of these findings were independently scored by four experienced observers, in 3-chamber and 4-chamber CMR cines, for both normal subjects and patients with RBBB. These motion patterns were found to be strongly associated with the presence of RBBB. While only moderately sensitive, they were quite specific for RBBB, when present. In particular, with ROC analysis, a combined feature set of the findings in the 4-chamber view had an area under the curve of 0.81.This previously undescribed set of RBBB-associated early-systolic regional motion features (delayed apex-ward motion of the RV base, "reverse septal flash", and "basal bulge") is strongly suggestive of RBBB when present, particularly in the 4-chamber view. Although here evaluated with CMR, it is also likely to be associated with RBBB when seen with other cardiac imaging modalities.

Right ventricular and left ventricular ejection fraction in pediatric patients with normal hearts: first-pass radionuclide angiocardiography

First-pass radionuclide angiocardiography was used to estimate right ventricular (RV) ejection fraction (EF) and left ventricular (LV) EF in infants, children, and teenagers with normal hearts. The right ventricle was analyzed in 74 patients and the left ventricle in 72 patients. Mean RVEF for the group was 0.53 +/- 0.06 (range 0.43 to 0.73); mean LVEF for the group was 0.68 +/- 0.09 (range 0.49 to 0.86). Lower values tended to be present in younger patients. However, there was no statistical difference in EFs between age groups and no linear correlation between magnitude of EF and age or EF and heart rate for either ventricle. Data obtained demonstrated that RVEF and LVEF in children with normal hearts are similar to those in adults with normal cardiovascular systems. A RVEF of 0.41 to 0.47 or a LVEF of 0.50 to 0.59 would suggest borderline systolic function; a RVEF less than 0.41 (mean -2 SD) or LVEF less than 0.50 (mean -2 SD) would be considered abnormal when this technique of first-pass radionuclide angiocardiography is used.

Ventricular dynamics after surgical closure of VSD

Twenty patients varying in age between 5 and 20 years at the time of surgical closure of VSD were studied 2 to 9 years postoperatively. Ventricular function was studied by echocardiography and measurement of systolic time intervals for the left and right ventricles and the findings were related to clinical and haemodynamic results of operation. The VSD was closed in all instances and the haemodynamic situation was normalized in all but 2 patients who had persisting pulmonary vascular disease. Right bundle branch block (RBBB) was recorded in 11 instances and in 5 there was an associated left axis deviation (LAD), suggesting left anterior hemiblock. LAD occurred as an isolated anomaly in another 2 patients. The heart size was within normal limits in all the patients. Abnormal septal motion (ASM) was recorded in 13 of the 20 patients, but other echocardiographic analyses, such as LV end-diastolic dimension, left atrial/aortic root ratio, posterior wall velocity index and maximal endocardial velocity, were all within predicted normal limits. There was an almost uniform prolongation of both left and right pre-ejection periods. left and right ejection period as a rule remained normal and gave an increased PEP/ET ratio, indicating the presence of postoperative ventricular dysfunction also in instances with complete normalization of the haemodynamic situation. Suggested background mechanisms for these findings are the frequent occurrence of conduction defects postoperatively, the likelihood of altered ventricular compliance and possibly also as a cause of ASM postoperative presence of an opened pericardial sac.