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Alboni P. Alternating anterior and posterior fascicular block and left septal fascicular block. J Electrocardiol 2024; 85:66-68. [PMID: 38889497 DOI: 10.1016/j.jelectrocard.2024.05.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/10/2024] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
Electrocardiogram of a patient affected by hypertensive cardiomyopathy showed an anterior fascicular block pattern and in right precordial leads an anterior displacement of QRS complex, characterised by a well evident jump of r wave from V1 to V2. Lead V2 showed qR morphology with embryonic q wave and very tall R wave. Septal q waves were not present in leads I and aVL. A subsequent electrocardiogram showed a posterior fascicular block pattern and the same findings in right precordial leads. Septal q waves were not present in inferior leads. Other causes of anterior displacement of QRS complex were ruled out by clinical/instrumental investigation. These findings are highly suggestive of left septal (middle) fascicular block coexisting with anterior and posterior fascicular block.
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Affiliation(s)
- Paolo Alboni
- Section of Cardiology, Ospedale Privato Quisisana, Ferrara, Italy.
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de Alencar Neto JN. Letter to editor: Right fascicles: A call for empirical evidence. J Electrocardiol 2024; 83:118. [PMID: 38448256 DOI: 10.1016/j.jelectrocard.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
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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] [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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Barold SS. Controversies about the terminology of "trifascicular" block. J Cardiovasc Electrophysiol 2023; 34:2122-2123. [PMID: 37702184 DOI: 10.1111/jce.16059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/28/2023] [Indexed: 09/14/2023]
Affiliation(s)
- S Serge Barold
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Scheffer MK, De Marchi MFN. This Could Mean a True Tetrafascicular Intraventricular Block-Reply. JAMA Intern Med 2023; 183:393. [PMID: 36848098 DOI: 10.1001/jamainternmed.2022.6941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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Suwanwalaikorn M, Prasitlumkum N, Chokesuwattanaskul R. A clue to the triples from an echo. J Arrhythm 2022; 39:88-91. [PMID: 36733327 PMCID: PMC9885305 DOI: 10.1002/joa3.12802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/23/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Narut Prasitlumkum
- Department of CardiologyUniversity of California RiversideRiversideCaliforniaUSA
| | - Ronpichai Chokesuwattanaskul
- Division of Cardiology, Department of Medicine, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial HospitalBangkokThailand
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Transient tall R waves in lead V2: What is the mechanism? J Electrocardiol 2022; 73:120-121. [PMID: 35843201 DOI: 10.1016/j.jelectrocard.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022]
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Transitory R wave growth in the midst of ST-segment elevation myocardial infarction: A case of left septal fascicular block with atypical electrocardiographic presentation. J Electrocardiol 2022; 72:39-43. [DOI: 10.1016/j.jelectrocard.2022.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/26/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022]
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Abstract
Many advances in the knowledge of medical science are due to the observation of an unknown phenomenon that remains an open question. A plausible hypothesis must be demonstrated and proved through a scientific method in order to be accepted by the scientific community and the same results must be reached by following either the same or different techniques. The original case described by Rosenbaum MB et al., in this review triggered a series of anatomic and physiologic investigations with clinical and experimental observations that supported the trifascicular nature of the intraventricular conduction system of the heart and the concept of hemiblocks. The recognition and description of the left fascicular blocks made by the Argentinian School of Electrocardiology bridged an important gap in electrocardiography and many electrocardiograms that could not be explained until that moment could finally be understood. This review intends to redefine reliable criteria for the electrocardiographic and vectorcardiographic diagnosis of left fascicular blocks [hemiblocks]. The anatomy of the left bundle branch is also discussed to better understand the incidence, prevalence, clinical significance and main causes of left anterior and left posterior hemiblock either isolated or associated with right bundle branch block. This review offers the reader a reappraisal of the trifascicular nature of the intraventricular conduction system regarding the anatomy of the left bundle branch system and its pathophysiological and clinical significance.
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Affiliation(s)
- Marcelo V Elizari
- Emeritus Professor of Cardiology, School of Medicine, Salvador University, President, Academia, Nacional de Medicina de Buenos Aires, Buenos Aires, Argentina
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Rajjoub Al-Mahdi K, Sánchez Vega JD, Rajjoub Al-Mahdi EA. Response to ECG, September 2020. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2020; 73:848. [PMID: 32980120 DOI: 10.1016/j.rec.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Kinán Rajjoub Al-Mahdi
- Pabellón Docente, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
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Rajjoub Al-Mahdi K, Sánchez Vega JD, Rajjoub Al-Mahdi EA. Respuesta al ECG de septiembre de 2020. Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2020.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Del Castillo M, Hamzeh I, Birnbaum Y. Tall R Waves in Precordial Electrocardiogram Leads. Tex Heart Inst J 2020; 47:47-48. [PMID: 32148455 DOI: 10.14503/thij-19-7056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Playán-Escribano J, Martínez-Losas P, Cobos-Gil MÁ. Electrocardiographic Changes After Angioplasty of the Left Anterior Descending Coronary Artery. Circulation 2019; 139:1550-1553. [PMID: 30883220 DOI: 10.1161/circulationaha.118.038518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Anderson KP. Left bundle branch block and the evolving role of QRS morphology in selection of patients for cardiac resynchronization. J Interv Card Electrophysiol 2018; 52:353-374. [PMID: 30128803 DOI: 10.1007/s10840-018-0426-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/23/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The clinical significance of left bundle branch block (LBBB) has recently expanded with the discovery of a strong association with better outcomes in patients receiving cardiac resynchronization therapy. METHODS Several milestones have contributed to the current understanding on the role of LBBB in clinical practice. RESULT Sunao Tawara described the arrangement of components of what he called the cardiac conduction system from the atrioventricular node to the terminal Purkinje fibers that connect to the working myocardium, and his hypotheses on how it functions remain current. Mauricio Rosenbaum and colleagues developed the bifascicular model of the left-sided conduction system that explains the characteristic electrocardiographic changes associated with propagation disturbances in its components. Andrés Ricardo Pérez-Riera and others have disputed the bifascicular model as oversimplified and have emphasized the role of the left septal fascicle. Marcelo Elizari and colleagues have explained the importance of masquerading bundle branch block. Elena Sgarbossa and colleagues developed a scheme to recognize ST elevation myocardial infarction in patients with left bundle branch block which remains current after more than 20 years. Enrique Cabrera and others identified electrocardiographic signs of remote myocardial infarction. CONCLUSION Substantial progress has been made in the understanding of LBBB, yet its role in clinical practice continues to evolve and important gaps remain to which research should be directed.
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Affiliation(s)
- Kelley P Anderson
- Department of Cardiology 2D2, Marshfield Clinic, Marshfield, 1000 North Oak Avenue, Marshfield, WI, 54449, USA.
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Leonelli FM, Bagliani G, De Ponti R, Padeletti L. Intraventricular Delay and Blocks. Card Electrophysiol Clin 2018; 10:211-231. [PMID: 29784481 DOI: 10.1016/j.ccep.2018.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
From the atrioventricular node, electrical activation is propagated to both ventricles by a system of specialized conducting fibers, His Purkinje System (HPS), guaranteeing a fast, synchronous depolarization of both ventricles. From the predivisional common stem, a right and left branch separate, subdividing further in a fairly predictable fashion. Synchronous ventricular activation results in a QRS with specific characteristics and duration of less than 110 milliseconds. Block or delay in any part of the HPS changes the electrocardiographic (ECG) morphology. This article discusses the use and limitations of standard ECG in detecting abnormal ventricular propagation in specific areas of the HPS.
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Affiliation(s)
- Fabio M Leonelli
- Cardiology Department, James A. Haley Veterans' Hospital, University of South Florida, Tampa, FL, USA.
| | - Giuseppe Bagliani
- Cardiology Department, Arrhythmology Unit, Foligno General Hospital, Foligno, Italy; Cardiovascular Diseases Department, University of Perugia, Perugia, Italy
| | | | - Luigi Padeletti
- Heart and Vessels Department, University of Florence, Florence, Italy; IRCCS Multimedica, Sesto San Giovanni, Italy
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Pérez-Riera AR, Barbosa-Barros R, Penachini da Costa de Rezende Barbosa M, Daminello-Raimundo R, de Abreu LC. Transient left septal and anterior fascicular block associated with type 1 electrocardiographic Brugada pattern. J Electrocardiol 2017; 51:145-149. [PMID: 28919216 DOI: 10.1016/j.jelectrocard.2017.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Indexed: 11/19/2022]
Abstract
The left septal fascicular block (LSFB) or blockage of the middle fibers of the left bundle branch is probably caused mainly by - in the developed world - the proximal obstruction of the left anterior descending artery (LAD) before its first anterior septal perforator branch (S1). The association of transient LSFB and left anterior fascicular block (LAFB) - left bifascicular block - and the electrocardiographic type 1 Brugada pattern (BrP) has not been described in the literature yet.
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Affiliation(s)
- Andrés Ricardo Pérez-Riera
- Design of Studies and Scientific Writing Laboratory in the Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil.
| | - Raimundo Barbosa-Barros
- Coronary Center of the Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | | | - Rodrigo Daminello-Raimundo
- Design of Studies and Scientific Writing Laboratory in the Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil
| | - Luiz Carlos de Abreu
- Design of Studies and Scientific Writing Laboratory in the Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil
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Pérez-Riera AR, Nadeau-Routhier C, Barbosa-Barros R, Baranchuk A. Transient Left Septal Fascicular Block: An Electrocardiographic Expression of Proximal Obstruction of Left Anterior Descending Artery? Ann Noninvasive Electrocardiol 2015; 21:206-9. [PMID: 25940584 DOI: 10.1111/anec.12271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Andrés R Pérez-Riera
- Cardiology Discipline, ABC Faculty, ABC Foundation, Santo André, São Paulo, Brazil
| | | | - Raimundo Barbosa-Barros
- Coronary Center of the Hospital of Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Brazil
| | - Adrian Baranchuk
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Canada
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Pérez-Riera AR, Baranchuk A, Chiale PA. About Left Septal Fascicular Block. Ann Noninvasive Electrocardiol 2015; 20:202-3. [DOI: 10.1111/anec.12267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Adrian Baranchuk
- Heart Rhythm Service; Kingston General Hospital; Queen's University; Kingston Ontario Canada
| | - Pablo A. Chiale
- Centro de Arritmias Cardíacas de la Ciudad Autónoma de Buenos Aires; División Cardiología; Hospital General de Agudos J.M. Ramos Mejía; Buenos Aires Argentina
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Ibarrola M, Chiale PA, Pérez-Riera AR, Baranchuk A. Phase 4 left septal fascicular block. Heart Rhythm 2014; 11:1655-7. [DOI: 10.1016/j.hrthm.2014.05.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Indexed: 11/16/2022]
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Nikus K. Antonio Bayés de Luna — the man behind the BaMa ECG Symposia. J Electrocardiol 2014; 47:745-7. [DOI: 10.1016/j.jelectrocard.2014.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Indexed: 10/25/2022]
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Pérez-Riera AR, Baranchuk A. Unusual conduction disorder: left posterior fascicular block + left septal fascicular block. Ann Noninvasive Electrocardiol 2014; 20:187-8. [PMID: 25041715 DOI: 10.1111/anec.12185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
A 44-year-old man with aortic valve insufficiency and stenosis underwent aortic valve replacement depicting interesting ECG changes. This unique case is discussed, contributing to the understanding of a trifascicular left intraventricular conduction system.
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Tas S, Aksoy E, Buyukbayrak F, Antal A, Donmez G, Bakal RB, Zeybek R, Sunar H. Prognostic significance of the absence of normal septal Q waves before aortic valve replacement. J Electrocardiol 2013; 46:368-74. [PMID: 23498092 DOI: 10.1016/j.jelectrocard.2013.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Indexed: 11/16/2022]
Abstract
PURPOSE Aim of this study was to investigate the prognostic significance of absence of septal Q waves in patients scheduled for aortic valve replacement. MATERIAL AND METHODS Sixty-one patients who underwent isolated aortic valve replacement for aortic stenosis were retrospectively evaluated. Septal Q waves were defined as Q waves of<2mm in amplitude and<40ms in width and absence of septal Q waves was defined as simultaneous loss of Q waves from at least three of the leads I, aVL, V5 and V6. Septal Q waves were absent in 17 patients (Group AQ, 27.8%) and were present in 44 patients (Group PQ, 72.1 %) preoperatively. Newly developed AV block>1st degree and newly developed left bundle branch block were primary endpoints. RESULTS Preoperatively, absence of normal septal Q waves was significantly associated with increased risk of postoperative AV block (HR: 11.18, range 1.37-91.21, 95% CI, p=0.02) whereas it was not associated with increased risk for newly developed LBBB (HR: 3.15 0.62-15.83, 95% CI, p=0.16). CONCLUSION Absence of normal septal Q waves in the preoperative ECG may predict further delay in conduction which might develop in the early postoperative course of aortic valve replacement.
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Affiliation(s)
- Serpil Tas
- Kartal Kosuyolu Heart and Research Hospital, Istanbul, Turkey
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Acunzo RS, Konopka IV, Sanchéz RA, Pizzarelli N, Wells FC, Baranchuk A, Chiale PA. Right bundle branch block and middle septal fiber block with or without left anterior fascicular block manifested as aberrant conduction in apparent healthy individuals: Electro-vectorcardiographic characterization. J Electrocardiol 2013; 46:167-72. [PMID: 23498753 DOI: 10.1016/j.jelectrocard.2012.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Right bundle branch block (RBBB) evident in the precordial ECG leads may be associated with evidence of left bundle branch involvement in the limb leads. Any of the components of the left bundle can be involved, and this complex interventricular conduction abnormality has previously been described in patients with underlying heart disease. OBJECTIVES To analyze the electro-vectorcardiographic manifestations of RBBB with left middle septal fiber block (LMSFB), with or without left anterior fascicular block (LAFB) in premature atrial beats of patients without apparent structural heart disease. METHODS Twelve patients (8 men/4 women; mean age: 32±8years) with premature atrial contractions with this conduction abnormality were included. Surface 12 simultaneous lead ECG recordings and the corresponding vectorcardiographic loops were analyzed. RESULTS The QRS complexes with RBBB and also LMSFB persisted for between 150 and 190ms. There were no q waves in lead I. The maximum spatial vector (72-86ms) was directed posteriorly, superiorly, and leftward, and the terminal forces were oriented anteriorly, inferiorly and rightward. In 10 patients, small q waves were apparent in leads V1-V2 and the frontal QRS axis was -60° and -70°, with the 46ms vector located at -50°±5. All of these patients most probably had LAFB in addition to LMSFB. In two patients, the initial electrical forces were directed anteriorly, inferiorly, and leftward, and the 46ms vector axis in the frontal plane was 6° and 11°, respectively, indicating absence of LAFB. CONCLUSIONS The combination of RBBB and LMSFB occurring in patients without apparent structural heart disease may be related to the simultaneous occurrence of block of conduction through these components of the Purkinje network. The anterior fascicle of the left bundle may also be involved.
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Affiliation(s)
- Rafael S Acunzo
- Division of Cardiology, Ramos Mejía Hospital, Buenos Aires, Argentina.
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Delay in or block of conduction through the middle (septal) fibers of the left bundle branch: can it be recognized on the body surface electrocardiogram? J Electrocardiol 2012; 45:461-2. [DOI: 10.1016/j.jelectrocard.2012.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Indexed: 11/21/2022]
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