Left Posterior Hemiblock Research Articles

Prevalence of prolonged QTc interval among HIV infected patients on highly active antiretroviral therapy (HAART) and its relationship with CD4 cells count and viral load at a tertiary hospital in North Eastern Nigeria.

Patients living with HIV infection remain at increased risk of cardiovascular diseases and sudden cardiac death. Various prevalence of electrocardiographic (ECG) abnormalities among HIV-infected patients were reported: Attamah et al reported the prevalence of electrocardiographic abnormalities among HIV-infected patients as 34.5%, while Orunta et al reported a prevalence of 42.9%, and Njoku et al reported a prevalence of 93.0%. Human immunodeficiency virus-infected patients are at increased risk of developing prolonged QT interval. Sani et al reported the prevalence of prolonged corrected QT interval among HIV-infected patients as 45.0%. Innocent et al reported a prevalence of48.0%, while Ajala et al reported a prevalence of 18%. Prolonged QTc interval increases the risk of premature ventricular contraction which can degenerate into ventricular tachycardia and or ventricular that can result in sudden cardiac death. The study was a cross-sectional conducted among HIV-infected patients receiving HAART at the Federal Medical Centre Nguru, Yobe State, North Eastern Nigeria. One hundred and seven (107) subjects were recruited into the study comprising thirty-three (37.0%) males and 70(65.4%) females. The mean CD4 cell count, and viral load of the studied patients were 612.64±34.75 cells/μL and4646.30±58.68 copies/mL respectively. Twenty (18.7%) patients had prolonged QTc interval, this gave us the prevalence of prolonged QTc in this study as 18.7%. The commonest cardiac rhythm was sinus rhythm (69.2%), followed by sinus tachycardia (26.2%) and atrial fibrillation 5(4.7%). Other electrocardiographic findings include First-degree atrioventricular block was seen in seven (6.5%) patients, Premature ventricular contractions were found in16.8%, RBBB was observed in 2.8%, 3.7% of patients had LBBB and 4.7% had left posterior hemiblock. The distribution of QTc interval according to CD4 cells count and viral revealed a statistically significant difference across the groups. All the patients with prolonged QTc interval had lower CD4 cells count and higher viral load suggesting that HIV disease severity is associated with prolonged QTc interval. In conclusion, the study revealed that the prevalence of prolonged QTc interval among HIV infected patients on highly active antiretroviral therapy was found to be 18.7%, and that HIV disease severity increases the risk of developing prolonged QTc interval.

Clinical and echocardiographic outcomes with new-onset left bundle branch block after SAPIEN-3 transcatheter aortic valve replacement.

New-onset left bundle branch block (LBBB) can develop after transcatheter aortic valve replacement (TAVR) resulting in worse outcomes. Describe clinical and echocardiographic outcomes with new-onset LBBB after TAVR. We included consecutive patients who underwent transfemoral-TAVR with SAPIEN-3 (S3) valve between April 2015 and December 2018. Exclusion criteria included pre-existing LBBB, right BBB, left anterior hemiblock, left posterior hemiblock, wide QRS ≥ 120ms, prior permanent pacemaker (PPM), and nontransfemoral access. Among 612 patients, 11.4% developed new-onset LBBB upon discharge. The length of stay was longer with new-onset LBBB compared with no LBBB [3 (2-5) days versus 2 (1-3) days; p < 0.001]. New-onset LBBB was associated with higher rates of 30-day PPM requirement (18.6% vs. 5.4%; p < 0.001) and 1-year heart failure hospitalizations (10.7% vs. 4.4%; p = 0.033). There was no difference in 3-year mortality between both groups (30.9% vs. 30.6%; p = 0.829). Further, new-onset LBBB was associated with lower left ventricular ejection fraction (LVEF) at both 30 days (55.9 ± 11.4% vs. 59.3 ± 9%; p = 0.026) and 1 year (55 ± 12% vs. 60.1 ± 8.9%; p = 0.002). These changes were still present when we stratified patients according to baseline LVEF (≥50% or <50%). New-onset LBBBs were associated with a higher 1-year LV end-diastolic volume index (51.4 ± 18.6 vs. 46.4 ± 15.1 ml/m2 ; p = 0.036), and LV end-systolic volume index (23.2 ± 14.1 vs. 18.9 ± 9.7 ml/m2 ; p = 0.009). Compared with resolved new-onset LBBB, persistent new-onset LBBB was associated with worse LVEF and higher PPM at 1 year. New-onset LBBB after S3 TAVR was associated with higher PPM requirement, worse LVEF, higher LV volumes, and increased heart failure hospitalizations, with no difference in mortality.

Impact of new-onset left bundle branch block on clinical and echocardiographic outcomes after TAVR with SAPIEN-3 valve

Abstract Background New left bundle branch block (LBBB) is a common finding after transcatheter aortic valve replacement (TAVR) that can result in worse outcomes after TAVR. We aim to investigate the impact of new-onset LBBB after TAVR using the SAPIEN-3 (S3) valve. Methods Consecutive patients who underwent transfemoral-TAVR with S3 valve between April 2015 and December 2018 were included. Exclusion criteria included pre-existing LBBB, right bundle branch block, left anterior hemiblock, left posterior hemiblock, wide QRS ≥120 msec, prior permanent pacemaker (PPM), and non-transfemoral access. Results Among 612 patients, 11.4% developed new-onset LBBB upon discharge. Implantation depth was the only predictor of new-onset LBBB (OR 1.294; 95% CI 1.121–1.493; p&amp;lt;0.001). The median (IQR) length of stay was longer with new-onset LBBB [3 (2–5) days vs. 2 (1–3) days; p&amp;lt;0.001]. New-onset LBBB was associated with higher thirty-day PPM requirement (18.6% vs. 5.4%; p&amp;lt;0.001) including those implanted after discharge (4.3% vs. 0.9%; p=0.02). There was no difference in 3-year all-cause mortality between both groups (30.9% vs. 30.6%; log-rank p=0.829). Further, new-onset LBBB was associated with lower left ventricular ejection fraction (LVEF) at both 30 days (55.9±11.4% vs. 59.3±9%; p=0.026) and 1 year (55±12% vs. 60.1±8.9%; p=0.002) despite no differences at baseline. These changes were still present when we stratified patients according to baseline LVEF (≥50% or &amp;lt;50%). We also noted higher mean LV end-diastolic volume index (51.4±18.6 vs. 46.4±15.1 ml/m2; p=0.036), and LV end-systolic volume index (23.2±14.1 vs. 18.9±9.7 ml/m2; p=0.009) with new-onset LBBB at 1 year. Lastly, there were significantly higher rates of heart failure readmissions at 1 year with new-onset LBBB (10.7% vs. 4.4%; log-rank p=0.033). Conclusion Among our cohort of S3 recipients, new-onset LBBB was associated with higher PPM requirement, worse LVEF, higher LV volumes and increased risk of heart failure hospitalizations. However, it did not affect mortality in the short-to-intermediate post-TAVR period. Funding Acknowledgement Type of funding sources: None. Figure 1. All-cause Survival

Expert consensus document on automated diagnosis of the electrocardiogram: The task force on automated diagnosis of the electrocardiogram in Japan. Part 1: Nomenclature for diagnosis and abnormal findings.

As these terms should accurately represent the abnormal findings and conditions as much as possible, we propose to unify these terms into terminologies that are not confusing and easy to understand for everyone.

Fascicular Blocks: Update 2019.

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.

Association between decreasing estimated glomerular filtration rate and risk of cardiac conduction defects in patients with type 2 diabetes

AimWe aimed to assess the association between decreasing estimated glomerular filtration rate (eGFR) or abnormal albuminuria and the risk of certain cardiac conduction defects in patients with type 2 diabetes mellitus (T2DM). MethodsWe examined a hospital-based sample of 923 patients with T2DM discharged from our Division of Endocrinology over the years 2007–2014. Standard electrocardiograms (ECGs) were performed in all patients. eGFR was estimated by using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, whilst albuminuria was measured by an immuno-nephelometric method on morning spot urine samples. ResultsA total of 253 (27.4%) patients had some type of cardiac conduction defects on standard ECGs (defined as at least one heart block among first-degree atrioventricular block, second-degree block, third-degree block, left bundle branch block, right bundle branch block, left anterior hemi-block or left posterior hemi-block). Prevalence of patients with eGFRCKD-EPI < 30 mL/min/1.73 m2, eGFRCKD-EPI 59–30 mL/min/1.73 m2 or abnormal albuminuria (i.e. urinary albumin-to-creatinine ratio ≥ 30 mg/g) were 7.0%, 29.4% and 41.3%, respectively. After adjustment for known cardiovascular risk factors, diabetes-related variables and potential confounders, there was a significant, graded association between decreasing eGFR values and risk of any cardiac conduction defects [adjusted-odds ratios of 2.05 (95% CI: 1.2–3.5), 2.85 (95% CI: 1.6–5.1) and 3.62 (95% CI: 1.6–8.1) for eGFRCKD-EPI 89–60, eGFRCKD-EPI 59–30 and eGFRCKD-EPI < 30 mL/min/1.73 m2, respectively]. Conversely, abnormal albuminuria was not independently associated with an increased risk of any conduction defects (adjusted-odds ratio: 1.09, 95% CI: 0.7–1.6). ConclusionDecreasing eGFR is independently associated with an increased risk of cardiac conduction defects in hospitalized patients with T2DM.

Bundle branch blocks and/or hemiblocks complicating acute myocardial ischemia or infarction.

Despite the bulk of anatomical and histologic evidence supporting the existence of three fascicules in the left branch of the His bundle, the concept of a bifascicular system proposed by Rosenbaum and his school has been adopted by the cardiological community as a practical teaching tool. Left anterior hemiblock (LAH) refers to block of the antero-superior branch of the left branch which is small and left posterior hemiblock (LPH) to block of the postero-inferior branch which is larger. The LAH is more common that the LPH and often associated with a complete right bundle branch block (RBBB). Coronary artery disease (CAD) is a major cause of hemiblocks. In this review article, we discuss various aspects of the relation of hemiblocks with CAD. We looked at the prevalence of LAH in consecutive patients undergoing coronary angiography and who had a significant coronary lesion in one vessel or more. In all patients with LAH, a significant lesion of the left anterior descending coronary artery was present, with in the majority of patients, an impairment of the left ventricular function. Bifascicular block (RBBB with LAH or LPH) can complicate acute myocardial infarction and is often associated with a poor prognosis and the presence of heart failure. Thrombolysis and or early angioplasty in acute myocardial infarction have significantly improved the prognosis and reduced the mortality associated with bifascicular block. Left anterior hemiblock pattern was also observed during angina pectoris occurring at rest or induced by exercise or atrial pacing. In these circumstances, LAH is transient and is likely to be due to ischemia in the anterolateral wall related to a lesion of the main trunk or the proximal left anterior descending coronary artery with the postero-inferior wall being first depolarized. The presence of bifascicular block in acute myocardial infarction still is associated with an unfavorable prognosis as compared to non-bundle branch block patients because of the common association with heart failure and other comorbidities.

Association Between Intraventricular Conduction Disorders and Intrahospital Prognosis in Patients with Acute Coronary Syndrome

Background: Acute coronary syndrome (ACS) is one of the most common heart diseases. Interventricular conduction disorders are complications of acute myocardial infarctions and have different types, such as left and right bundle branch blocks and left anterior and posterior hemiblocks. The prognosis of this disease can affect therapeutic methods, duration of hospitalization, and timely intervention decisions. Therefore, in this study, we evaluated the relationship between interventricular conduction disorders and the prognosis of patients with ACS.Methods: Using the convenience sampling method, this analytical case-control study was conducted on 140 patients with ACS (61 patients in the case group and 79 patients in the control group) who were treated from March to August 2013. The underlying variables of the risk factors for ACS were evaluated, along with prognostic evaluation factors, in two groups: a case group (patients with interventricular conduction disorders) and a control group (patients without interventricular conduction disorders). Data were analyzed with SPSS v. 17 software using the chi-squared test, the analysis of variance test, Student’s t-test, and Fisher’s exact test. Results: The mean age of patients was 64.1 ± 5.8 years in the case group and 62.9 ± 8.8 years in the control group. No significant relationship was observed between ACS risk factors, such as hyperlipidemia, diabetes, hypertension, previous myocardial infarction, and smoking, and the prognosis of patients with ACS. The mean ejection fraction was 39.7 in the case group and 45.1 in the control group, so a significant relationship existed between the two groups (P&lt;0.05). In addition, systolic heart failure was more common in the case group than in the control group.Conclusion: We found that the presence of auscultation (rales sound) and shortness of breath on the first day of hospital admission in the case group was significantly different from the control group (P&lt;0.05). Furthermore, the ejection fraction in the case group was lower than in the control group, and the frequency of mitral regurgitation in the case group was higher than in the control group. These factors can effectively predict the prognosis of patients with ACS. Finally, we found that interventricular conduction disorders weakened the prognosis of patients with ACS.

Nonalcoholic fatty liver disease is associated with an increased risk of heart block in hospitalized patients with type 2 diabetes mellitus.

Recent studies suggested that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiac tachyarrhythmias (mainly atrial fibrillation) in patients with and without type 2 diabetes mellitus. The aim of this study was to examine whether an association also exists between NAFLD and heart block. We have retrospectively evaluated a hospital-based cohort of 751 patients with type 2 diabetes discharged from our Division of Diabetes and Endocrinology during years 2007–2014. Standard electrocardiograms were performed on all patients. Diagnosis of NAFLD was based on ultrasonography, whereas the severity of advanced hepatic fibrosis was based on the fibrosis (FIB)-4 score and other non-invasive fibrosis markers. Overall, 524 (69.8%) patients had NAFLD and 202 (26.9%) had heart block (defined as at least one block among first-degree atrio-ventricular block, second-degree block, third-degree block, left bundle branch block, right bundle branch block, left anterior hemi-block or left posterior hemi-block) on electrocardiograms. Patients with NAFLD had a remarkably higher prevalence of any persistent heart block than those without NAFLD (31.3% vs. 16.7%, p<0.001); this prevalence was particularly increased among those with higher FIB-4 score. NAFLD was associated with a threefold increased risk of prevalent heart block (adjusted-odds ratio 3.04, 95% CI 1.81–5.10), independently of age, sex, hypertension, prior ischemic heart disease, hemoglobin A1c, microvascular complication status, use of medications and other potentially confounding factors. In conclusion, this is the largest cross-sectional study to show that NAFLD and its severity are independently associated with an increased risk of prevalent heart block in hospitalized patients with type 2 diabetes.

Relation of elevated serum uric acid levels to first-degree heart block and other cardiac conduction defects in hospitalized patients with type 2 diabetes

AimsSeveral studies have reported that moderately elevated serum uric acid levels are associated with an increased risk of tachyarrhythmias (mainly atrial fibrillation) in patients with and without type 2 diabetes mellitus (T2DM). It is currently unknown whether an association also exists between elevated serum uric acid levels and cardiac conduction defects in patients with T2DM. MethodsWe retrospectively analyzed a hospital-based sample of 967 patients with T2DM discharged from our Division of Endocrinology over the years 2007–2014. Standard electrocardiograms were performed on all patients and were interpreted by expert cardiologists. ResultsOverall, 267 (27.6%) patients had some type of conduction defects on electrocardiograms (defined as at least one block among first-degree atrio-ventricular block, second-degree block, third-degree block, left bundle branch block, right bundle branch block, left anterior hemi-block or left posterior hemi-block). Patients in the 3rd serum uric acid tertile had a higher prevalence of any cardiac conduction defects than those belonging to 2nd or 1st tertile, respectively (35.8% vs. 25.0% vs. 22.6%; p<0.0001). Elevated serum uric acid levels were associated with a nearly twofold increased risk of cardiac conduction defects after adjustment for age, sex, hemoglobin A1c, diabetes duration, metabolic syndrome, chronic kidney disease, chronic obstructive pulmonary disease, ischemic heart disease, valvular heart disease and medication use (adjusted-odds ratio 1.84, 95% confidence intervals 1.2–2.9; p=0.009). ConclusionsModerately elevated serum uric acid levels are associated with an increased prevalence of any cardiac conduction defects in hospitalized patients with T2DM, independent of multiple risk factors and potential confounding variables.

68. Unusual presentation of mediastinal lymphoma and role of cardiac MRI

Diffuse large B cell lymphoma (DLBCL) is the most common histologic subtype of non-Hodgkin lymphoma (NHL) accounting for approximately 25% of NHL cases. One of the common subtype of DLBCL is primary DLBCL of the mediastinum. Case report this 65 year old female known to have diabetes and hypertension presented to our emergency department with history of epigastric pain for last 2 h. Her electrocardiogram (ECG) showed right bundle block with left posterior hemi-block representing bi-fasicular block with minimal ST segment depression in leads V4–V6. Her initial routine laboratory results revealed normal renal function, blood counts and liver profile. Her cardiac bio-markers were elevated with Troponin I of 1.22 and CPK of 35. She was admitted by the cardiology team diagnosis of non-ST elevation myocardial infarction (NSTEMI). She was started with usual anti-ischemic. Next morning she had echocardiography which revealed a large mediastinal mass on the antero-lateral aspect of the left ventricle infiltrating the basal lateral and anterior wall. This mass was encasing the origin of the great vessels and also infiltrating the left atrium occluding the Left atrial appendage and left upper pulmonary vein. It was infiltrating the Right ventricular outflow tract causing obstruction to the flow with a gradient of 52 mmHg. Cardiac MRI showed multiple cardiac masses, the largest of which was originating from the anterior mediastinum and going posteriorly then infiltrating RV and within the right ventricular out-flow tract (RVOT) causing significant obstruction. The magnetic resonance characteristics of the intra cardiac and extra cardiac masses were same and with features of central necrosis was highly suggestive of lymphoma. The CT scan of the chest and abdomen showed the same cardiac findings as of cardiac MRI and multiple enlarged thoracic, retroperitoneal, left common iliac lymph nodes. Patient had CT guided Lymph node biopsy from the mediastinal lymph node and was reported as Diffuse Large B-Cell lymphoma of non-germinal center subtype with anaplastic features. Bone marrow biopsy was also performed as well PET oncology to complete staging process. The case was discussed in the multi-disciplinary oncology board and planned for chemotherapy with CHOP with no need for any cardiac intervention at this moment. The care of the patient was transferred to the hematology team with close follow-up by cardiology team. He received the chemotherapy for 4 cycles and had a repeat cardiac MRI which showed the complete resolution of the intra-cardiac mass. Patients with DLBCL typically present with a rapidly enlarging symptomatic mass, most usually nodal enlargement in the neck or abdomen, or, in the case of primary mediastinal large B cell lymphoma, the mediastinum, but may present as a mass lesion anywhere in the body. The prognosis is good as the rate of remission with chemotherapy is good. The cardiac MRI can assist in diagnosis.

Right Bundle Branch Block: A Masquerader in Acute Coronary Syndrome.

Dear Editor, We read with interest the recent case reported by Pozen et al. that was published in your esteemed journal.[1] Physicians are often faced with a patient with suspected acute myocardial infarction (MI) and bundle branch block (BBB). There are different questions, depending on the presence of a left BBB (LBBB) or a right BBB (RBBB) that need to be answered in such scenarios. Is the conduction disturbance new or a presumably new occurrence? Often, this question cannot be answered with certainty. If at all the patient has acute coronary syndrome (ACS), does the BBB mask any electrocardiographic features of MI with ST-segment elevation? Is it possible to assess the area of myocardium at risk with the use of investigations such as echocardiography (ECHO)?[2] Although, an RBBB does not theoretically mask the repolarization phase; nor can a preexisting Q-wave, minor ST-segment elevation in the anterior leads (i.e., V1–V4) be missed, because these are “compensated” by the pseudonormalization of the negative T-waves. RBBB as a consequence of the current anterior MI is most commonly related to the proximal occlusion of left descending coronary artery with compromise of circulation in the septal arteries supplying the bundle branches. Due to anterior location of the right ventricle than that of the left ventricle, activation of the right ventricular free wall can neutralize the abnormal septal forces associated with an anteroseptal MI. Therefore, in most patients with an anteroseptal infarction, abnormal Q waves in right precordial leads is mostly manifest during RBBB showing the classical qRBBB pattern, due to delayed activation of the right ventricle. Very rarely, early depolarization of the right ventricular free wall could mask the abnormal Q waves in some patients with an anteroseptal MI.[3] The analysis of HERO-2 demonstrated that in MI, RBBB occurs alone or in combination with left anterior hemiblock or left posterior hemiblock. In the setting of an anterior ST-segment elevation MI (STEMI), the presence of an RBBB is associated with a higher risk of death when compared with that of patients with normal conduction, as these patients experienced more extensive MI due to involvement of the proximal left anterior descending artery or the left main coronary artery.[4] Rarely with the involvement of the atrioventricular (A-V) branch of the right coronary artery, can RBBB be associated with an inferior wall MI with ST-T changes in lead II, III, avF without the pathological Q waves in the anterior leads. The changes in the inferior leads can often be subtle and missed. The prognosis of RBBB due to the involvement of the A-V branch of the right coronary artery, RBBB associated with an inferior infarction, does not portend a worse prognosis as often a small amount of myocardium is jeopardized.[4] This was observed in the case described by Pozel et al. as well.[1] In the case scenario described by Pozen et al., it would have been interesting to know the ECHO findings and the presence of regional wall motion abnormalities, if any. The demonstration of regional wall motion abnormalities can help accelerate the treatment decisions in doubtful cases. The mystery of electrocardiographic findings of RBBB, borderline troponin levels, and atypical chest pain, especially in diabetics and the elderly patients, can be often solved by performing the screening ECHO to rule out the diagnosis of ACS. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Epidemiology and pattern of fascicular block following ST-Elevated acute myocardial infarction

Aim: The aim of the study was to observe the epidemiology and pattern of fascicular block following ST elevated acute myocardial infarction (AMI).Background: Fascicular block following S-T elevated acute myocardial infarction is often seen in CCU. It predicts poorer in-hospital outcome and signifies underlying extensive myocardial damage with jeopardized conducting system.Materials and Method: This one year prospective observational study was carried out among the S-T elevated AMI patients in the CCU of NICVD during the period of January 2004 to December 2004. Hundred consecutive patients of first attack of AMI with or without fascicular block were included in this study. The patients suffering from congenital heart disease, cardiomyopathy, valvular heart disease and the patients having permanent pacemaker or preexisting syndrome were excluded from the study. Case selection was done with the help of history, physical examination, twelve leads surface ECG and echocardiography.Results: The mean age of the studied patients was 54.2±10.0 years. Highest percentage (38%) was in the age group 51-60 years. The mean age of male Patients was 51.0±9.9 years. Analysis reveals that the mean age of the female patients was significantly higher than the male patients. Among the studied patients, highest percentage had history of smoking 67% followed by hypertension (39%), diabetes mellitus (39%) etc. Among the studied patients 66% had anterior MI and 34% had inferior MI. Highest percentage of patients presented with isolated RBBB (54.0%), followed by LBBB (18%), bi-fascicular (16.0%), tri-fascicular block (8.0%) and isolated LAHB (4.0%). Among the patients with anterior MI, highest percentage presented with RBBB (42.4%) followed by bi-fascicular block (24.2%), LBBB (15.2%) and LAHB (6%) whereas with inferior MI, 76.5 percentage had RBBB followed by LBBB (23.5%).Conclusion: In this study majority of the patients were male. Most of the patients were in the age group 50-60 years. Number of anterior MI was higher (66%) than inferior MI (34%). Anterior MI showed highest incidence of fascicular block than inferior MI which is statistically significant. Among the fascicular blocks, RBBB was the highest (54.0%) and next common fascicular block was LBBB, least common was LAHB. Left posterior hemi-block was not found in this study. Statistical variation among the different types of fascicular blocks observed in this study was significant. Smoking was the most important risk factor. So, fascicular blocks following acute MI are more prone to develop complications than acute MI without fascicular block. Message is that patient with fascicular blocks following acute MI needs special care and treatment.Bangladesh Journal of Medical Science Vol.14(2) 2015 p.186-189

Electrocardiographic features of patients with earthquake related posttraumatic stress disorder

To analyze electrocardiographic features of patients diagnosed with posttraumatic stress disorder (PTSD) after the Van-Erciş earthquake, with a shock measuring 7.2 on the Richter scale that took place in Turkey in October 2011. Surface electrocardiograms of 12 patients with PTSD admitted to Van Erciş State Hospital (Van, Turkey) from February 2012 to May 2012 were examined. Psychiatric interviews of the sex and age matched control subjects, who had experienced the earthquake, confirmed the absence of any known diagnosable psychiatric conditions in the control group. A wide range of electrocardiogram (ECG) parameters, such as P-wave dispersion, QT dispersion, QT interval, Tpeak to Tend interval, intrinsicoid deflection durations and other traditional parameters were similar in both groups. There was no one with an abnormal P wave axis, short or long PR interval, long or short QT interval, negative T wave in lateral leads, abnormal T wave axis, abnormal left or right intrinsicoid deflection duration, low voltage, left bundle branch block, right bundle branch block, left posterior hemiblock, left or right axis deviation, left ventricular hypertrophy, right or left atrial enlargement and pathological q(Q) wave in either group. The study showed no direct effect of earthquake related PTSD on surface ECG in young patients. So, we propose that PTSD has no direct effect on surface ECG but may cause electrocardiographic changes indirectly by triggering atherosclerosis and/or contributing to the ongoing atherosclerotic process.

Papillary Muscle Ventricular Tachycardia: Another Zigsaw Puzzle to Be Solved

Papillary Muscle Ventricular Tachycardia: Another Zigsaw Puzzle to Be Solved

Pathophysiology of atrioventricular conduction disturbances in sports practitioners

In athletes practicing endurance sports, atrioventricular conduction disturbances may be physiological. This holds true for first-degree atrioventricular blocks, type 1 second-degree atrioventricular blocks, and slight ventricular activation delays (slurred S wave in V1). On the contrary, right (RBBB) and left bundle branch blocks (LBBB) and fascicular blocks (left anterior [LAH] and left posterior hemiblocks [LPH]), either isolated or associated with RBBB, are rare in asymptomatic athletes. The latter can be the consequence of structural heart disease or primary degeneration of the intraventricular conduction system (Lev-Lenègre disease). In our experience, LPH and LPH+RBBB have always a pattern of familial recurrence. LAH+RBBB may be familial (40-60%). Isolated RBBB is rarely familial. LBBB is never familial. Families with hereditary conduction disorders may also have a history of juvenile sudden death. Patients with LBBB may show coronary artery anomalies. The long-term prognosis of intraventricular conduction disorders in asymptomatic subjects, without apparent heart disease, is unknown.

Frequency of Conduction Disturbances After Edwards SAPIEN Percutaneous Valve Implantation

Disturbances in atrioventricular conduction and the additional need for a permanent pacemaker are recognized complications after transcatheter aortic valve replacement (TAVR). We analyzed the incidence of postprocedural conduction disorders and the need for permanent pacemaker implantation in patients undergoing TAVR with the Edwards SAPIEN valve. In 125 consecutive patients with symptomatic, severe aortic stenosis undergoing TAVR, a standard 12-lead electrocardiogram was obtained before and serially after the procedure. The cohort was divided into 2 groups with regard to the post-TAVR appearance of conduction disturbances, defined as left bundle branch block, right bundle branch block, fascicular hemiblock, atrioventricular block, and the need for a permanent pacemaker. The patients with and without conduction disturbances were compared. After TAVR, 19 patients (15.2%) met the study definition of a "new conduction defect" and 5 patients (4%) required a permanent pacemaker because of an advanced atrioventricular block. New left bundle branch block appeared in 5 patients (4%) and left anterior hemiblock in 9 (7.2%). No new right bundle branch block or left posterior hemiblock was observed. Although most baseline, echocardiographic, and procedural characteristics were equally distributed, the patients with new conduction disturbances more often had diabetes mellitus and peripheral vascular disease. Also, they more often were taking an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, and the procedure was performed more often with apical access (12 [63.2%] vs 7 with femoral access [36.8%], p = 0.002). In conclusion, although the incidence of conduction disturbances was high after TAVR using the Edwards SAPIEN valve, with a significant increase in the rate of left bundle branch block and left anterior hemiblock, the need for permanent pacemaker implantation after TAVR with this valve remained low.

Prevalence of ventricular conduction blocks in the resting electrocardiogram in a general population: The Health 2000 Survey

AimsThe prevalence of eight different ventricular conduction blocks and their association with risk factors and major cardiovascular diseases were studied in a major Finnish population study. MethodsData, including 12-lead electrocardiograms, were collected from 6315 subjects. The prevalence of left bundle branch block (LBBB), right bundle branch block (RBBB), non-specific ventricular block, incomplete LBBB, incomplete RBBB, R–R′-pattern, left anterior hemiblock (LAHB), and left posterior hemiblock (LPHB) was calculated for both genders in three age groups. Their association with risk factors and cardiovascular diseases was studied. ResultsR–R′-pattern was the most common ventricular conduction block in all age groups (3.9%, p<0.001 for comparison between groups), but it showed no association with cardiovascular diseases. Males had more RBBB (1.5% vs. 0.7%, p<0.001), incomplete LBBB (1.8 vs. 0.4, p<0.001) and non-specific ventricular block (1.1% vs. 0.1%, p<0.001).With increasing age (<45years vs. >55years) LBBB, RBBB and LAHB (0 vs. 2.2%, 0.3 vs. 2.2%, 0.2 vs. 1.9% respectively, p-values<0.001) became more prevalent. LBBB, RBBB and non-specific ventricular conduction block were associated with coronary heart disease (angina pectoris in 28.3, 20.3 and 22.9%, respectively) and heart failure (25.0, 10.1 and 11.4%, respectively). LBBB and RBBB were also associated with peripheral vascular disease (8.8%). ConclusionsVentricular conduction blocks differ in prevalence between sexes and age groups. They also show disparate association with cardiovascular diseases. These differences need to be taken into consideration in everyday clinical practice.

Primary angioplasty in acute myocardial infarction with right bundle branch block: should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy?

AimsThe current guidelines recommend reperfusion therapy in acute myocardial infarction (AMI) with ST-segment elevation or left bundle branch block (LBBB). Surprisingly, the right bundle branch block (RBBB) is not listed as an indication for reperfusion therapy. This study analysed patients with AMI presenting with RBBB [with or without left anterior hemiblock (LAH) or left posterior hemiblock (LPH)] and compared them with those presenting with LBBB or with other electrocardiographic (ECG) patterns. The aim was to describe angiographic patterns and primary angioplasty use in AMI patients with RBBB.Methods and resultsA cohort of 6742 patients with AMI admitted to eight participating hospitals was analysed. Baseline clinical characteristics, ECG patterns, coronary angiographic, and echocardiographic data were correlated with the reperfusion therapies used and with in-hospital outcomes. Right bundle branch block was present in 6.3% of AMI patients: 2.8% had RBBB alone, 3.2% had RBBB + LAH, and 0.3% had RBBB + LPH. TIMI flow 0 in the infarct-related artery was present in 51.7% of RBBB patients vs. 39.4% of LBBB patients (P = 0.023). Primary percutaneous coronary intervention (PCI) was performed in 80.1% of RBBB patients vs. 68.3% of LBBB patients (P< 0.001). In-hospital mortality of RBBB patients was similar to LBBB (14.3 vs. 13.1%, P = 0.661). Patients with new or presumably new blocks had the highest (LBBB 15.8% and RBBB 15.4%) incidence of cardiogenic shock from all ECG subgroups. Percutaneous coronary intervention was done more frequently (84.8%) in patients with new or presumably new RBBB when compared with other patients with blocks (old RBBB 66.0%, old LBBB 62.3%, new or presumably new LBBB 73.0%). In-hospital mortality was highest (18.8%) among patients presenting with new or presumably new RBBB, followed by new or presumably new LBBB (13.2%), old LBBB (10.1%), and old RBBB (6.4%). Among 35 patients with acute left main coronary artery occlusion, 26% presented with RBBB (mostly with LAH) on the admission ECG.ConclusionAcute myocardial infarction with RBBB is frequently caused by the complete occlusion of the infarct-related artery and is more frequently treated with primary PCI when compared with AMI + LBBB. In-hospital mortality of patients with AMI and RBBB is highest from all ECG presentations of AMI. Restoration of coronary flow by primary PCI may lead to resolution of the conduction delay on the discharge ECG. Right bundle branch block should strongly be considered for listing in future guidelines as a standard indication for reperfusion therapy, in the same way as LBBB.

Frequency of Cardiac Conduction Disturbances After Balloon Aortic Valvuloplasty

Disturbances in atrioventricular conduction are well-recognized complications of transcatheter aortic valve replacement. Percutaneous balloon aortic valvuloplasty (BAV) is a requisite step in transcatheter aortic valve replacement; however, the contribution of the BAV to atrioventricular conduction disturbances has not been elucidated. The present analysis was undertaken to ascertain the incidence and type of electrocardiographic changes associated with BAV and to consider the role of BAV in the conduction abnormalities after transcatheter aortic valve replacement. In 271 consecutive patients with symptomatic, severe aortic stenosis undergoing BAV, a standard 12-lead electrocardiogram was obtained before and serially after the procedure. Each was examined by experienced electrocardiographers. The cohort was divided into 2 groups with regard to the post-BAV appearance of conduction disturbances. The clinical and procedural characteristics of patients with these disturbances were compared to those in whom no conduction disturbance appeared. After BAV, 23 patients (8.5%) met the study definition of "new conduction defect": 4 patients (1.5%) required permanent pacemaker implantation for advanced atrioventricular block. New left bundle branch block appeared in 9 (3.3%) and left anterior hemiblock in 7 (2.6%). New right bundle branch block appeared in 2 and left posterior hemiblock in 1. No significant difference was found in the clinical or procedural characteristics. The ratio of the balloon size to the left ventricular outflow tract diameter was 1.21 ± 1.6 in those with new conduction defects and 1.15 ± 0.12 (p = 0.032) in those without. In conclusion, BAV is associated with a low incidence of cardiac conduction disturbances and a requirement for permanent ventricular pacing. The size of the valvuloplasty balloon should be carefully selected to avoid oversizing, which can lead to the development of postprocedure conduction disturbances.