Exercise-induced Left Bundle Branch Block Research Articles

Exercise-induced left bundle branch block: unmasking dynamic mitral regurgitation in ischaemic heart disease.

Exercise-induced left bundle branch block: unmasking dynamic mitral regurgitation in ischaemic heart disease.

LIDOCAINE-INDUCED INTERMITTENT LEFT BUNDLE BRANCH BLOCK AND CHATTERJEE PHENOMENON

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: The frequency of new onset left bundle branch block (LBBB) during anaesthesia and surgery is rare. The most common causes for LBBB are structural heart diseases, acute myocardial infarction, dilated cardiomyopathy, heart failure, and exercise-induced LBBB[1]. We present a rare case of Lidocaine-induced Intermittent Left Bundle Branch Block. CASE PRESENTATION: A 63-year-old female with no medical history had hysterectomy/high uterosacral ligament suspension as an elective procedure for uterine prolapse. The baseline EKG was normal. She went to the operating room as scheduled, but after the injection of 100 mg local Lidocaine, she developed a LBBB on the EKG with ST-T changes (Figure-1). The surgery was aborted, and cardiology was consulted Cardiac enzymes were normal. Upon evaluation by the cardiology team, the patient had no particular complaints, and soon her LBBB had resolved spontaneously without any intervention. A follow-up EKG done a few hours later showed normal sinus rhythm with evidence of T-wave inversion suggestive of cardiac memory or "Chatterjee's phenomenon" (Figure-2). Echocardiogram and Nuclear stress testing were performed, and which were negative for ischemic changes. DISCUSSION: There have been several reports of adverse effects of lidocaine on cardiac conduction after standard doses of intravenous lidocaine. These have included the appearance of type II second-degree heart block, asystole, and complete heart block in an infant. One of the first cases of transient LBBB induced by lidocaine was reported back in 1989 by Tagliente et al[2]. It is not understood how lidocaine may induce a transient LBBB; however, the literature has suggested that lidocaine in high doses can cause a conduction delay within the Purkinje system and subsequently leading to a conduction block. Cardiac memory, or Chatterjee's phenomenon, first described in 1969 by Kanu Chatterjee et al., is defined as a deep inversion of T-wave with ST depression in the un-paced heart following ventricular pacing[3]. It has also been described to occur in other patients with abnormal electricity, including those with intermittent LBBB, WPW, and episodic tachycardia. CONCLUSIONS: On rare occasions, Lidocaine can induce intermittent left bundle branch block. REFERENCE #1: Sarter BH, Hook BG, Callans DJ, Marchlinski FE. Effect of bundle branch block on local electrogram morphologic features: implications for arrhythmia diagnosis by stored electrogram analysis. American heart journal. 1996;131(5):947-52. REFERENCE #2: Tagliente TM, Jayagopal S. Transient left bundle branch block following lidocaine. Anesthesia & Analgesia. 1989;69(4):545-7. REFERENCE #3: Chatterjee K, Harris A, Davies G, Leatham A. Electrocardiographic changes subsequent to artificial ventricular depolarization. British heart journal. 1969;31(6):770 DISCLOSURES: No relevant relationships by Mostafa Abohelwa, source=Web Response No relevant relationships by Monica Botros, source=Web Response No relevant relationships by Zeyad Elharabi, source=Web Response No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by Peter Khalil, source=Web Response No relevant relationships by Sima Shahbandar, source=Web Response No relevant relationships by Victor Test, source=Web Response

Exercise-Induced Bundle Branch Block - an Infrequent Incidence

We describe an elderly woman who underwent a treadmill test preoperatively and was found to have Exercise-induced Left Bundle Branch Block without chest pain. Coronary angiogram was done which revealed a 70% stenosis in the fi rst diagonal branch of Left Anterior Descending Artery and a 40% lesion in proximal Right Coronary Artery. Available literature attributes rate-dependent transient conduction defects to obstructive lesions of coronary arteries, slow arterial blood fl ow, vasospasms as well as pathology in the Bundle of His.

Expanding benefits from cardiac resynchronization therapy to exercise‐induced left bundle branch block in advanced heart failure

Indications of cardiac resynchronization therapy (CRT) do not include exercise‐induced left bundle branch block, but functional impairment could be improved with CRT in such cases. A 57‐year‐old woman with idiopathic dilated cardiomyopathy (ejection fraction 23%) presented with New York Heart Association Class IV and recurrent hospitalizations. During heart transplant evaluation, a new onset of intermittent left bundle branch block was observed on the cardiopulmonary exercise test. CRT was implanted, and 97% resynchronization rate was achieved. In 12 month follow‐up, both clinical and prognostic exercise parameters improved. In patients with heart failure with reduced ejection fraction and no left bundle branch block at rest, exercise test can uncover electromechanical dyssynchrony that may benefit from CRT.

Expanding Benefits from Cardiac Resynchronization Therapy to Exercise-Induced Left Bundle Branch Block in the Setting of Advanced Heart Failure: A Case Report

Introduction Exercise-induced left bundle branch block (LBBB) is rarely observed in exercise testing, and usually implies a worse prognosis. Cardiac resynchronization therapy (CRT) is well validated in patients with heart failure with reduced ejection fraction (HFrEF) and LBBB. Although the indications of CRT do not include exercise-induced LBBB, the functional impairment secondary to dynamic electromechanical dyssynchrony could potentially be improved with CRT. Case Report A 57-year-old woman with long-standing idiopathic dilated cardiomyopathy (ejection fraction of 23%) presented with clinical deterioration to NYHA functional class 4 and recurrent hospitalizations despite optimal medical treatment. During evaluation for cardiac transplant, new-onset of intermittent LBBB was observed on the cardiopulmonary exercise test (her resting QRS duration was 100ms). A stress echocardiography showed exertion-induced intraventricular and interventricular dyssynchrony. Cardiac resynchronization therapy was then indicated, and 97% resynchronization rate was obtained. There was clinical improvement to NYHA class 2 and no hospitalizations since the CRT initiation. Functional reassessment at 6 and 12 months post-implant demonstrated significant improvement in prognostic exercise parameters (Figure). She currently remains off the transplant list. Summary In HFrEF patients with no LBBB at rest, exercise test and stress echocardiography may uncover dynamic electromechanical dyssynchrony that may benefit from CRT. This is the first report of CRT for treatment of an advanced heart failure patient with worsening symptoms attributed to exercise-induced LBBB.

Exercise induced left bundle branch block in isotopic exercise test. Findings and prognostic value.

Exercise-induced left bundle branch block (EI-LBBB) is a rare circumstance of unknown significance. The purpose of this paper is to describe the scintigraphic features and the prognostic value of this finding. We reviewed the features of 1,885 patients who had visited our department to undergo GATED-SPECT ergometry to diagnose ischaemic heart disease. Seven patients showed EI-LBBB throughout the exercise testing. Coronary angiography was performed in 4 of them. Patients were followed-up over an average period of time of 30±8 months. The onset of major cardiovascular events was recorded during the follow-up period. The prevalence of EI-LBBB was 0.37%. Six out of 7 patients were women. Myocardial function and perfusion were normal in 3 patients. Three patients had fixed perfusion defects and one patient had a reversible defect. Two out of the 4 patients showing perfusion defects presented a moderate-severe decrease of the left ventricular ejection fraction. None of the 4 patients with perfusion defects were found to have coronary disease on coronary angiography. The prevalence of EI-LBBB among the patients that came to undergo GATED-SPECT ergometry was very low. The finding was more frequent in women. In our series, 2 patients presented non-ischaemic structural heart disease, but no patient was diagnosed with coronary artery disease. In our patients the presence of EI-LBBB did not relate to a greater risk of experiencing a major cardiovascular event.

Exercise-induced left bundle branch block – A case report with stress-echocardiographic assessment

We report the case of a 51-year-old male who presented with exertional chest discomfort and dyspnea concurring with an exercise-induced left bundle branch block (EI-LBBB). Possible underlying causes and treatment options are presented and discussed. The case represents the first stress-echocardiographic assessment of a case with EI-LBBB, performed in order to document a possible left ventricular dyssynchrony during the EI-LBBB and thereby the possible treatment option of biventricular pacemaker implantation.

Exercise Induced Left Bundle Branch Block Accompanied by Chest Pain

Exercise-induced left bundle branch block is a rare condition that has been reported along with and without demonstrable cardiac abnormalities. We describe the case of a 73-year-old female with chest pain on execration. Coronary angiography revealed normal findings. She underwent a treadmill stress test. During the exercise left bundle branch block with concomitant chest pain was demonstrated. Chest pain was relieved with cessation of exercise.

Exercise-Induced Left Bundle Branch Block and Chest Pain in the Absence of Coronary Artery Disease: A Case Report and Review of the Literature

Exercise-induced left bundle branch block (LBBB) is rare, but portends higher major cardiac events risk in the presence of coronary disease. It is more benign without coronary disease. We present a case of chest pain with exercise-induced LBBB with unusual features. A 59-year-old female was referred for evaluation of atypical chest pain. She was on medications for hypertension, dyslipidemia, and hypothyroidism. She denied tobacco or alcohol use. She underwent a Bruce protocol exercise treadmill test. Her resting heart rate was 76 beats per minute (BPM) and blood pressure was 150/85 mmHg. She was able to exercise for 8 min, achieving 9 METS. Her peak heart rate was 140 BPM without ischemic ST changes. At that heart rate, she developed LBBB, and complained of her usual chest discomfort. Her peak blood pressure was 209/83 mmHg. The test was terminated, and the patient was allowed to rest. Her rhythm continued to be LBBB for 2 min and 30 sec into recovery until, at a heart rate of 110 BPM, a premature ventricular contraction (PVC) resulted in resolution of LBBB. Shortly thereafter, her chest pain resolved. Subsequent cardiac catheterization revealed normal coronary arteries, ejection fraction (EF), and wall motion. Exercise-induced LBBB associated with chest pain may be a manifestation of underlying coronary disease and indicate poor prognosis. It renders the stress test uninterpretable and mandates its termination. However, certain clinical and electrocardiographic features may provide clues to non-ischemic etiology. J Med Cases • 2013;4(12):828-830 doi: http://dx.doi.org/10.4021/ jmc1576w

Exercise-induced left bundle branch block: an infrequent phenomenon: Report of two cases

Exercise-induced left bundle branch block (EI-LBBB) is infrequent phenomenon. We present two patients with angina pectoris who developed EI-LBBB during exercise tolerance test. The first patient with typical angina pectoris had significant obstructive coronary artery disease (CAD) requiring percutaneous coronary intervention of multiple lesions including placement of drug eluting stents. The second patient had atypical chest pain without signs of CAD at all. EI-LBBB occurred at a heart rate of 80 bpm and 141 bpm in the first and second patient, respectively. EI-LBBB remained visible through the test till the recovery period in the first patient at a heart rate of 83 bpm and disappeared at 96 bpm in the second patient. Both patients with this infrequent phenomenon are discussed and the literature is reviewed.

Exercise-Induced Left Bundle Branch Block and Chest Pain in the Absence of Coronary Artery Disease: A Case Report and Review of the Literature

Exercise-Induced Left Bundle Branch Block and Chest Pain in the Absence of Coronary Artery Disease: A Case Report and Review of the Literature

Bloqueio completo do ramo esquerdo esforço-induzido: prevalência e prognóstico

Exercise-induced left bundle branch block (EI-LBBB) is an infrequent finding. Its prevalence and prognostic significance are not clear.To evaluate, in a longitudinal study, the prevalence and prognostic significance of EI-LBBB in American war veterans.We evaluated 9,623 patients submitted to an exercise test (ET) in treadmill between 1987 and 2007. The outcomes were compared between those with normal TE, the ones with EI-LBBB and the ones with down-sloping ST-segment. Mortality and causes of death were identified while blinded to the ET results.In this prospective cohort, 6,922 individuals had normal ET results (57.2 ± 11.4 years), 1,739 had abnormal ST-segment depression (62.7 ± 9.8 years), and 38 had EI-LBBB (65.2 ± 11.9 years). The prevalence of EI-LBBB was 0.38%. After 8.8 years, there were 1,699 deaths due to all-cause mortality and 610 cardiovascular (CV) deaths; coronary artery disease and heart failure were more prevalent in patients with EI-LBBB. Patients with EI-BCRE had a hazard ratio of 2.37 (p = 0.002) for all-cause mortality, but it was not significant when adjusted for age or when the CV death was the assessed outcome.EI-LBBB is a rare clinical finding. Individuals with BCRE-EI have higher all-cause mortality when compared to those with normal ET results. However, this fact is explained by the fact that these patients are significantly older and have more associated cardiovascular diseases.

Exercise-induced left bundle branch block and subsequent mechanical left ventricular dyssynchrony -resolved with pharmacological therapy

A 53-year-old man with depressed ejection fraction (EF) of 35% and QRS width of 88 ms at rest was admitted to our institution with a complaint of exertional chest discomfort and dyspnea. During treadmill exercise, left bundle-branch block (LBBB) with a QRS width of 152 ms occurred at a heart rate of 100 bpm. During LBBB, the patient showed significant mechanical dyssynchrony as evidenced by a two-dimensional speckle tracking radial strain of 260 ms (≥130 ms), defined as the time difference between anterior-septum and posterior wall. Five-month after carvedilol and candesartan administration, EF had improved to 49% and LBBB did not occur until a heart rate of 126 bpm was attained during treadmill exercise. It appears that pharmacological therapy may be useful for patients with heart failure and exercise-induced LBBB.

Exercise-induced left bundle branch block and propafenone administration

Exercise-induced left bundle branch block and propafenone administration

Exercise-induced left bundle branch block accompanied by chest pain: Correlation with coronary artery disease

A case of a 25-year-old woman with familiar hypercholesterolemia, who was admitted complaining for chest pain on exertion, is presented. She underwent a treadmill stress test and during the exercise left bundle branch block with concomitant chest pain in low heart rate (105/min) was demonstrated. After these findings TL-201 scintigraphy with dipyridamole infusion was performed: Chest pain and left bundle branch block appeared again during the test, and the stress TL-201 tomographic images showed reversible defect in the anterior wall. Finally, the young woman underwent coronary arteriography, which showed normal coronary vessels. The ergonovine test for coronary spasm was negative.

Exercise-induced left bundle branch block in a young female athlete

An 11-year-old female, in apparent good health, was referred to our Institute because of exercise-induced left bundle branch block detected during a Master's step test performed to obtain the clearance for competitive sport. The tests that we performed to investigate the possible causes were all negative. We suspect, however, that the left bundle branch block is the initial sign of cardiomyopathy. If our suspicions are correct, close follow-up is important to chart the possible progression of the disease.

Relation between neurohormonal activation and enhanced ventilatory response to exercise in patients with chronic congestive heart failure

O. Assessment of myocardial perfusion with thallium-201 scintigraphy in exercise-induced left bundle branch block: diagnostic value and clinical significance. Eur Heart J 1992;13:942–946. 18. Skalidis EI, Kochiadakis GE, Koukouraki SI, Parthenakis FI, Karkavitsas NS, Vardas PE. Phasic coronary flow pattern and flow reserve in patients with left bundle branch block and normal coronary arteries. J Am Coll Cardiol 1999;33: 1338–1346.

El bloqueo de rama izquierda inducido por el ejercicio en pacientes con y sin enfermedad coronaria

Exercise-induced left bundle-branch block does not always denote the presence of underlying coronary artery disease. The aim of this study was to analyze the clinical characteristics and evolution of patients with rate-dependent left bundle-branch block. 9,318 consecutive exercise stress studies were reviewed. The clinical characteristics and evolution (mean follow-up: 6.9 years) of 20 patients with exercise-induced left bundle-branch block in which coronary angiography had been performed were analyzed. Eight out of 20 patients had normal coronary arteries (group A) and 12 had coronary artery disease (group B). Peak O2 consumption, peak myocardial O2 consumption, and heart rate when block appeared (132 20 vs. 95.4 23 beats/min; p = 0.002) were significantly higher in group A. Seven of the 8 patients with normal coronary arteries had chest pain coinciding with the first beat of left bundle-branch block. There were no deaths during follow-up in group A, but permanent left bundle-branch block appeared in 5 patients of this group who experienced disappearance of exercise-related pain. There were 3 deaths in group B and 2 patients had acute myocardial infarction during follow-up. One patient in each group developed atrioventricular block and required pacemaker implantation. In contrast with patients with left bundle-branch block and coronary artery disease, the prognosis of patients with painful left bundle-branch block and normal coronary arteries is good. However, the development of permanent left bundle-branch block is frequent. Atrioventricular block, although rare, may occur.

What is the Significance of Exercise-Induced Left Bundle Branch Block?

What is the Significance of Exercise-Induced Left Bundle Branch Block?

Prognostic significance of exercise-induced left bundle-branch block.

Approximately 0.5% of all patients who undergo exercise testing develop a transient left bundle-branch block (LBBB) during exercise, but its prognostic significance is unclear. To determine whether exercise-induced LBBB is an independent predictor of mortality and cardiac morbidity. Matched control cohort study. Between September 1990 and February 10, 1994, 17277 exercise stress tests were performed on patients. Tertiary care, academic medical center. From the cohort, 70 cases of exercise-induced LBBB were identified. The controls comprised 70 individuals without LBBB at rest or during exercise that matched the 70 cases based on age, test date, sex, prior history of coronary artery disease, hypertension, diabetes, smoking, and beta-blocker use. All-cause mortality, percutaneous coronary intervention, open heart surgery, nonfatal myocardial infarction, documented symptomatic or sustained ventricular tachydysrhythmia, or implantation of a permanent pacemaker or an implantable cardiac defibrillator. A total of 37 events (28 events from the exercise-induced LBBB cases and 9 from the control cohort) occurred in 25 patients (17 exercise-induced LBBB patients and 8 control patients) during a mean follow-up period of 3.7 (0.9 years) (median, 3.8 years [range, 0.9-5.2 years]). There were 7 deaths, of which 5 occurred among patients with exercise-induced LBBB. Four-year Kaplan-Meier event rates were 19% among exercise-induced LBBB patients and 10% among controls (log-rank chi2, 5.2; P=.02). After further adjusting for small differences in age, exercise-induced LBBB remained associated with a higher risk of primary events (adjusted relative risk, 2.78; 95% confidence interval, 1.16-6.65; P=.02). Exercise-induced LBBB independently predicts a higher risk of death and major cardiac events.