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Pujol-López M, Tolosana JM, Upadhyay GA, Mont L, Tung R. Left Bundle Branch Block: Characterization, Definitions, and Recent Insights into Conduction System Physiology. Cardiol Clin 2023; 41:379-391. [PMID: 37321688 DOI: 10.1016/j.ccl.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
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Affiliation(s)
- Margarida Pujol-López
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - José M Tolosana
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, The University of Chicago Medicine, Heart and Vascular Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Lluís Mont
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, The University of Chicago Medicine, Heart and Vascular Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Elgassim MAM, Sanosi A, Elgassim MA. Transient Left Bundle Branch Block in the Setting of Cardiogenic Pulmonary Edema. Cureus 2021; 13:e19568. [PMID: 34804750 PMCID: PMC8592294 DOI: 10.7759/cureus.19568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2021] [Indexed: 11/05/2022] Open
Abstract
Cardiogenic pulmonary edema complicated by transient left bundle branch block (LBBB) is a relatively rare finding. We report a case of a 52-year-old woman with underlying heart failure but no structural heart disease who was referred for evaluation due to severe shortness of breath and documented LBBB on a 12-lead EKG. She was diagnosed with cardiogenic pulmonary edema due to medication noncompliance. With the resolution of her symptoms by treating her pulmonary edema with bisoprolol and furosemide, repeated EKG showed resolution of LBBB. A review of her medical records showed similar presentations of pulmonary edema associated with transient LBBB. In conclusion, to the best of our knowledge, transient LBBB associated with cardiogenic pulmonary edema is very uncommon. The etiology of transient LBBB remains unclear, however, the most likely theory that explains our patient's transient LBBB is a consequence of ventricular enlargement from fluid overload and cardiac muscle strain with dilatation, causing bundle conduction interruption. Our patient's cardiogenic pulmonary edema was complicated with transient LBBB in multiple previous presentations with a resolution of the LBBB after treating the underlying pulmonary edema.
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Affiliation(s)
| | - Amin Sanosi
- Internal Medicine, Hamad General Hospital, Doha, QAT
| | - Moayad A Elgassim
- Internal Medicine, Taylor's University Lakeside Campus, Subang Jaya, MYS
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Left Bundle Branch Block: Characterization, Definitions, and Recent Insights into Conduction System Physiology. Card Electrophysiol Clin 2021; 13:671-684. [PMID: 34689894 DOI: 10.1016/j.ccep.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
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Ko HC, Cho YH, Jang W, Kim SH, Lee HS, Ko WH. Transient left bundle branch block after posture change to the prone position during general anesthesia: A case report. Medicine (Baltimore) 2021; 100:e25190. [PMID: 33726011 PMCID: PMC7982238 DOI: 10.1097/md.0000000000025190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/25/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE The prone position is commonly used in spinal surgery. There have been many studies on hemodynamic changes in the prone position during general anesthesia. We report a rare case of transient left bundle branch block (LBBB) in a prone position. PATIENT CONCERN Electrocardiogram (ECG) of a 64-year-old man scheduled for spinal surgery showed normal sinus rhythm change to LBBB after posture change to the prone position. DIAGNOSIS Twelve lead ECG revealed LBBB. His coronary angio-computed tomography results showed right coronary artery with 30% to 40% stenosis and left circumflex artery with 40% to 50% stenosis. The patient was diagnosed with stable angina and second-degree atrioventricular block of Mobitz type II. INTERVENTION Nitroglycerin was administered intravenously during surgery. Adequate oxygen was supplied to the patient. After surgery, the patient was prescribed clopidogrel, statins, angiotensin II receptor blocker, and a permanent pacemaker was inserted. OUTCOME Surgery was completed without complications. After surgery, the transient LBBB changed to a normal sinus rhythm. The patient did not complain of chest pain or dyspnea. LESSON The prone position causes significant hemodynamic changes. A high risk of cardiovascular disease may cause ischemic heart disease and ECG changes. Therefore, careful management is necessary.
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Masson R, Bakhshi H, Haddad TM. Intermittent left bundle branch block and acute heart failure in trastuzumab-induced cardiotoxicity. BMJ Case Rep 2020; 13:13/7/e236009. [PMID: 32723779 DOI: 10.1136/bcr-2020-236009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A 70-year-old woman with HER2+/ER+ breast cancer on adjuvant trastuzumab therapy without a history of cardiovascular disease presented with respiratory failure from influenza and was found to have intermittent left bundle branch block (LBBB) with new onset systolic heart failure. Her course was complicated by polymorphic ventricular tachycardia and recurrent chest pain. Significant investigations included a normal cardiac MRI and cardiac catheterisation with unobstructed coronaries. It was determined that the aetiology of her heart failure was trastuzumab-induced cardiotoxicity after comprehensive workup. This case highlights an uncommon presentation of LBBB and the steps taken to diagnose a rare cardiomyopathy.
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Affiliation(s)
- Ravi Masson
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Hooman Bakhshi
- Department of Cardiology, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Tariq M Haddad
- Department of Cardiology, Inova Heart and Vascular Institute, Falls Church, Virginia, USA.,Department of Cardiology, Virginia Heart, Falls Church, Virginia, USA
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Tyagi A, Sethi AK, Agarwal V, Mohta M. Rate-dependent Left Bundle Branch Block during Anaesthesia. Anaesth Intensive Care 2019; 32:715-8. [PMID: 15535502 DOI: 10.1177/0310057x0403200521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Rate-dependent left bundle branch block during general anaesthesia is rare. Its occurrence makes electrocardiographic diagnosis of acute myocardial ischaemia or infarction difficult. It can also be confused with a slow rate ventricular tachycardia. We present a case of rate-dependent left bundle branch block in a patient with no previous history of ischaemic heart disease. Carotid sinus massage resulted in a decrease in heart rate and reversion to normal sinus rhythm.
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Affiliation(s)
- A Tyagi
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, Shahadra, Delhi, India
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Gonzva J, Viard FV, Jost D, Lefort H, Tourtier JP. Transient right bundle branch block in a patient with acute pulmonary embolism. J Electrocardiol 2016; 50:211-213. [PMID: 27817836 DOI: 10.1016/j.jelectrocard.2016.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Indexed: 11/25/2022]
Abstract
We report the case of an 86-year-old man found at home with acute chest pain and dyspnea. He presented some episodes of left chest pain combined with dyspnea. The physical examination revealed crackling sounds on the bases of the lungs without other anomalies. Electrocardiograms revealed a transient and complete right bundle branch block with inverted T waves in leads V1, V2, and V3. He was diagnosed with a proximal bilateral acute pulmonary embolism without acute cor pulmonale. We describe a case of a transient bundle branch block, without tachycardia or acute cor pulmonale, revealing a pulmonary embolism.
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Affiliation(s)
| | | | - Daniel Jost
- Emergency Medical Service, Fire Brigade of Paris, France
| | - Hugues Lefort
- Emergency Medical Service, Fire Brigade of Paris, France
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Bazoukis G, Tsimos K, Korantzopoulos P. Episodic Left Bundle Branch Block-A Comprehensive Review of the Literature. Ann Noninvasive Electrocardiol 2016; 21:117-25. [PMID: 27296905 DOI: 10.1111/anec.12361] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/10/2016] [Accepted: 01/19/2016] [Indexed: 01/09/2023] Open
Abstract
Episodic (transient/ intermittent) left bundle branch block (LBBB) has been associated with different conditions such as bradycardia, tachycardia, anesthesia, acute pulmonary embolism, changes in intrathoracic pressure, chest trauma, cardiac interventional procedures, mad honey poisoning, and in other clinical settings. Of note, exclusion of an acute coronary syndrome in the setting of episodic LBBB is of great importance. Moreover, episodic LBBB is sometimes symptomatic and may be associated with left ventricular systolic and/or diastolic dysfunction or conduction disturbances leading to syncope. This review article provides a comprehensive overview of the conditions associated with episodic LBBB and discusses the clinical impact of this phenomenon.
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Affiliation(s)
- George Bazoukis
- Department of Internal Medicine, General Hospital of Athens "Elpis,", Athens, Greece
| | - Konstantinos Tsimos
- First Department of Cardiology, University of Ioannina, Medical School, Ioannina, Greece
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Senoo K, Otsuka T, Suzuki S, Sagara K, Yamashita T. Impact of pulmonary vein isolation on left bundle branch block following tachycardia-induced cardiomyopathy in a patient with persistent atrial fibrillation. Intern Med 2014; 53:721-4. [PMID: 24694484 DOI: 10.2169/internalmedicine.53.1661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 61-year-old man was referred to our hospital with exertional dyspnea. Electrocardiography showed atrial fibrillation (AF) with a heart rate of 116 bpm and left bundle branch block (LBBB). Chest radiography demonstrated pulmonary congestion and cardiomegaly with a cardiothoracic ratio of 57%. Transthoracic echocardiography revealed a severely reduced left ventricular systolic function (ejection fraction: 32%), suggesting tachycardia-induced cardiomyopathy (TIC) due to AF. Following treatment for congestive heart failure and complete isolation of each pulmonary vein, the LBBB disappeared, with a complete recovery of the cardiac systolic function. This report describes a case of transient reversible LBBB associated with systolic dysfunction treated with catheter ablation.
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Affiliation(s)
- Keitaro Senoo
- Department of Cardiology, The Cardiovascular Institute, Japan
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Ting PC, Lin TS, Yang MW, Ho ACY. Spontaneous remission of left bundle branch block immediately after denitrogenation with inhalation of 100% oxygen prior to anesthetic induction. ACTA ANAESTHESIOLOGICA TAIWANICA : OFFICIAL JOURNAL OF THE TAIWAN SOCIETY OF ANESTHESIOLOGISTS 2010; 48:140-144. [PMID: 20864063 DOI: 10.1016/s1875-4597(10)60046-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 08/18/2009] [Accepted: 08/21/2009] [Indexed: 05/29/2023]
Abstract
Complete left bundle branch blocks have focused our attention, primarily because they are a sign predictive of mortality and a predictor of coexisting cardiovascular disease. Left bundle branch block (LBBB) is usually permanent but may occur transiently or intermittently. Spontaneous remission of LBBB rarely occurs during anesthesia. We present two patients in whom chronic LBBB reverted to normal sinus rhythm shortly following denitrogenation with inhalation of 100% oxygen during induction of anesthesia.
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Affiliation(s)
- Pei-Chi Ting
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, Republic of China
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Transient Left Bundle Branch Block: An Unusual Electrocardiogram in Acute Pulmonary Embolism. Am J Med Sci 2009; 337:381-2. [DOI: 10.1097/maj.0b013e3181907b25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Im KS, Jung HJ, Lee JM, Park K, Kim JB, Sim JC. Rate-dependent Left Bundle Branch Block during General Anesthesia - A case report -. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.3.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Kyung Sil Im
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Ju Jung
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myeong Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kuhn Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Bun Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Cheol Sim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Corda DM, Caruso LJ, Mangano D. Myocardial ischemia detected by transesophageal echocardiography in a patient undergoing peripheral vascular surgery. J Clin Anesth 2000; 12:491-7. [PMID: 11090738 DOI: 10.1016/s0952-8180(00)00200-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Prevention and early treatment of myocardial ischemia remain among the primary goals of the anesthesiologist taking care of high-risk patients, such as those undergoing vascular surgery. Guidelines have been published to assist in directing preoperative evaluation and optimization of cardiovascular status. Although perioperative monitoring allows early detection of ischemic events, all monitors have limitations that must be understood before they can be used effectively. We present a case of severe intraoperative myocardial dysfunction detected only by transesophageal echocardiography in a patient undergoing a peripheral vascular procedure. Preoperative and intraoperative management is also discussed.
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Affiliation(s)
- D M Corda
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610-0254, USA
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15
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Schultz DA, Wahl RL, Juni JE, Buda AJ, McMeekin JD, Struble LR, Tuscan MJ. Diagnosis of exercise-induced left bundle branch block at rest by scintigraphic phase analysis. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1986; 11:434-7. [PMID: 3011436 DOI: 10.1007/bf00261005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Accurate diagnosis of diseases of the ventricular conducting system is essential for their appropriate therapy. Some conduction abnormalities, such as exercise-induced left bundle branch block (EX-LBBB), are not apparent on resting electrocardiograms. Phase analysis of rest and exercise radionuclide ventriculograms (RVG's) was used to compare four EX-LBBB patients with six normal controls. All patients had normal resting electrocardiograms, ejection fractions, and visually normal wall motion. First harmonic phase images were generated reflecting the timing of ventricular contraction. Dynamic phase displays were reviewed and graded in a blinded fashion by three independent experienced observers. Phase angle histograms of the right and left ventricle were determined for both resting and exercise images. The mean phase angle and standard deviation were also calculated for each ventricle. Visual grading of the resting phase images failed to show a significant difference between normal patients and patients with EX-LBBB. Quantitative analysis, however, revealed a significant difference in mean phase angle differences (LV-RV) in resting studies: 0.8 degrees (+/- 1.9 degrees SEM) in normals versus 9.3 degrees (+/- 2.3 degrees SEM) in EX-LBBB patients (P less than 0.03). Exercise accentuated the phase angle differences: 1.8 degrees in normals vs. 31.2 degrees in EX-LBBB patients (P less than 0.001). Quantitative phase analysis of resting RVG's permits the diagnosis of cardiac conduction disease that is not apparent on the resting EKG and may result in better monitoring and treatment.
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Vasey C, O'Donnell J, Morris S, McHenry P. Exercise-induced left bundle branch block and its relation to coronary artery disease. Am J Cardiol 1985; 56:892-5. [PMID: 4061330 DOI: 10.1016/0002-9149(85)90777-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The records of 2,584 consecutive patients who underwent both treadmill exercise testing and coronary cineangiography were reviewed to determine the relation between exercise-induced, acceleration-dependent left bundle branch block (LBBB) and the presence of coronary artery disease (CAD). Rate-dependent LBBB during exercise was identified in 28 patients (1.1%), who were categorized according to their presenting symptoms: classic angina pectoris, atypical chest pain, symptomatic cardiac arrhythmia and asymptomatic. Asymptomatic patients underwent a screening exercise test. CAD was present in 7 of 10 patients who presented with classic angina pectoris, but 12 of 13 patients presenting with atypical chest pain had normal coronary arteries. All 10 patients in whom LBBB developed at a heart rate of 125 beats/min or higher were free of CAD, whereas 9 of 18 patients in whom LBBB developed at a heart rate of less than 125 beats/min had CAD. Normal coronary arteries were present in 3 patients who presented with angina and in whom both chest pain and LBBB developed during exercise. It is concluded that patients who present with atypical chest pain in whom rate-dependent LBBB develops on the treadmill are significantly less likely to have CAD than patients who present with classic angina; the onset of LBBB at a heart rate of 125 beats/min or higher is highly correlated with the presence of normal coronary arteries, regardless of patient presentation; and patients with angina in whom both chest pain and LBBB develop during exercise may have normal coronary arteries.
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Domino KB, LaMantia KL, Geer RT, Klineberg PL. Intraoperative diagnosis of rate-dependent bundle branch block. CANADIAN ANAESTHETISTS' SOCIETY JOURNAL 1984; 31:302-6. [PMID: 6722621 DOI: 10.1007/bf03007895] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Rate-dependent left bundle branch block (LBBB) occasionally occurs during anaesthesia when the heart rate exceeds a critical value. While it is usually a benign disorder, it may mask the electrocardiographic manifestations of myocardial ischaemia and the ST-T wave pattern associated with LBBB may be mistaken for those of ischaemia. This case report presents two cases in which rate-dependent LBBB was clearly documented during the perioperative period. It demonstrates the use of pharmacologic agents (e.g., atropine and neostigmine) and physiologic manipulations (e.g., carotid sinus massage) to alter the heart rate and confirm the diagnosis of benign rate-dependent LBBB in the operating room. These interventions should be used with caution in patients who have hypertension, angina, cerebrovascular, or AV node disease or in the setting of myocardial ischaemia or severe bundle branch disease.
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Watanabe Y, Kishi H. Permanent right bundle-branch block heralded by intermittent block and ventricular extrasystoles. A 13-year observation. BRITISH HEART JOURNAL 1982; 48:184-8. [PMID: 6178422 PMCID: PMC481225 DOI: 10.1136/hrt.48.2.184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
A patient is described in whom the occurrence of frequent ventricular extrasystoles of right ventricular origin and intermittent right bundle-branch block caused by interpolation of these extrasystoles heralded the slow development of permanent right bundle-branch block over a period of observation of 13 years. Such a clinical course suggested gradual progression of an organic lesion in the intraventricular conducting system. The differential diagnosis of intermittent bundle-branch block and aberrant intraventricular conduction, and possible mechanisms of ectopic impulse formation in the presence of bundle-branch block are discussed.
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Abstract
A 70-year-old woman was found to have an intermittent left bundle branch block. When her electrocardiogram showed normal conduction, T-wave inversions in leads V1-V3 appeared. These alterations suggested an anteroseptal infarction. However, the patient was asymptomatic, and the serum enzymes, technetium 99m pyrophosphate scan, and the thalium 201 scan were all negative. Thus the LBBB itself can produce T-wave in versions in the right precordial leads during the normal conduction phase which may simulate an acute myocardial infarction.
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Cokkinos DV, Demopoulos JN, Heimonas ET, Mallios C, Papazoglou N, Vorides EM. Electrocardiographic criteria of left ventricular hypertrophy in left bundle-branch block. Heart 1978; 40:320-4. [PMID: 147697 PMCID: PMC482000 DOI: 10.1136/hrt.40.3.320] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In order to determine whether the electrocardiographic criteria of left ventricular hypertrophy apply in the presence of left bundle-branch block we studied 79 cases of intermittent left bundle-branch block and compared the QRS voltage and axis before and after its onset. Cases of incomplete left bundle-branch block were excluded. There was a statistically significant correlation between pre- and post-left bundle-branch block values of R or S wave voltage in leads I, V1, V2, V5, and V6, the Sokolow index (R V5 or V6 + S V1), and the QRS axis. There was a statistically significant reduction in R wave voltage in leads I, V5, and V6, an increase in S wave voltage in V1 and V2, and leftward shift of QRS axis, but the Sokolow index remained unchanged, after the onset of left bundle-branch block. The Sokolow criteria for left ventricular hypertrophy apply satisfactorily even in the presence of left bundle-branch block, though specificity is low, but QRS axis is unhelpful.
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Reiffel JA, Antman EM, Casella AJ, Drusin R. Case studies: Simultaneous intermittent intraatrial and intraventricular conduction defects mimicking trifascicular conduction delay. J Electrocardiol 1977; 10:59-62. [PMID: 833525 DOI: 10.1016/s0022-0736(77)80032-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Both intermittent rate related left bundle branch block and intermittent rate related trifascicular conduction delay (left bundle branch block with marked H-V interval prolongation) have been previously described. However intermittent rate related intraatrial block with left bundle branch block has not. No only does the case presented herein reveal intermittent rate related intraatrial block with left bundle branch block, but also PR prolongation secondary to the intraatrial block. This combination mimicked intermittent trifascicular conduction delay. Electrophysiological testing allowed differentiation of this pseudotrifascicular defect from true trifascicular conduction delay.
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Lichstein E, Gupta PK, Chadda KD. Long-term survival of patients with incomplete bundle-branch block complicating acute myocardial infarction. Heart 1975; 37:924-30. [PMID: 1191453 PMCID: PMC482899 DOI: 10.1136/hrt.37.9.924] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Electrocardiograms and His bundle electrograms were reviewed in 28 patients with incomplete bilateral bundle-branch block complicating acute myocardial infarction. All had a His bundle electrogram at the time of pacemaker insertion; 10 had a second one. Of 23 patients with an initially abnormal HV interval (55 ms or greater), 15 died (65%), while only one died (20%) in the group of 5 with a normal HV interval. This difference is not statistically significant. Sequential His bundle electrograms were done in 6 of the 8 survivors with an initially abnormal HV interval, and 4 showed 10 to 15 ms decrease in HV interval. The disappearance of incomplete bilateral bundle-branch block occurred significantly more often in patients who survived (7 of 12) when compared with those who did not survive (2 of 16) (P less than 0.05). It is concluded that long-term survival is po-sible after incomplete bilateral bundle-branch block complicating acute myocardial infarction. The characteristics of the survivors include an initially normal HV interval, transient incomplete belateral bundle-branch block and a decreasing HV interval if it were initially abnormal.
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Cannom DS, Goodman DJ, Harrison DC. Electrophysiological studies in patients with rate-related intermittent left bundle-branch block. BRITISH HEART JOURNAL 1974; 36:653-9. [PMID: 4413215 PMCID: PMC458876 DOI: 10.1136/hrt.36.7.653] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Lichstein E, Gupta PK, Chadda KD, Liu HM, Sayeed M. Findings of prognostic value in patients with incomplete bilateral bundle branch block complicating acute myocardial infarction. Am J Cardiol 1973; 32:913-8. [PMID: 4757230 DOI: 10.1016/s0002-9149(73)80157-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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