Painful Left Bundle Branch Block Research Articles

Painful left bundle branch block syndrome: a case report

Painful left bundle branch block syndrome: a case report

Painful Left Bundle Branch Block

Painful Left Bundle Branch Block

A Clinical Case of “Painful” Left Bundle Branch Block in a Female Athlete: “Elective” or Neglected Nosographic Entity?

Painful left bundle branch block is a rarely diagnosed chest pain syndrome. This syndrome is caused by intermittent, frequency-dependent LBBB in the absence of myocardial ischemia. Its prevalence, mechanism, detailed electrocardiographic features and effective treatments are still not well understood. With this case report, the author describes the clinical course of an athlete undergoing competitive sports pre-participation screening that led to the diagnosis of painful left bundle branch block syndrome.

PO-01-044 THEOPHYLLINE FOR TREATMENT OF PAINFUL LEFT BUNDLE BRANCH BLOCK

Painful left bundle branch block (LBBB) is characterized by chest pain in setting of transient LBBB, in the absence of ischemia. Management has focused on pharmacological suppression of the sinus rate to prevent LBBB, or invasive therapy with permanent pacing. To determine the feasibility of using oral theophylline for treatment of painful LBBB. N/A A 71-year-old man presented for evaluation of exertional left-sided chest pain that resolved with rest. 12-lead electrocardiogram (ECG) showed sinus bradycardia at 54 bpm. Transthoracic echocardiogram was normal and coronary angiography showed non-obstructive coronary artery disease. Symptoms persisted despite treatment for microvascular angina with beta-blockers and ranolazine. Heart rate and ECG monitoring using an Apple watch demonstrated reproducible symptoms when heart rate increased above 80 bpm and resolution with decrease in heart rate below this threshold. Electrophysiology study demonstrated rate-related left bundle branch block and concurrent onset of symptoms with atrial pacing at a cycle length of 550 ms (∼109 bpm) (Panel A) and prompt resolution of symptoms with narrowing of QRS at lower pacing rates. Transient right bundle branch block was intentionally induced with catheter manipulation (Panel B) and atrial pacing produced 1:1 conduction down the left bundle with right bundle branch block up to 113 bpm with no symptoms and then to 2:1 block above the His (Panel C). Isoproterenol infusion allowed for atrial pacing up to 127 bpm without evidence of LBBB (Panel D). The patient was then discharged on theophylline 100 mg bid, which has a similar chronotropic and dromotropic effect as isoproterenol. He reported significant improvement in functional status with no recurrence in symptomatic LBBB. We report the first case of successful treatment of painful LBBB with oral theophylline. The mechanism may be improvement in conduction in damaged fibers to the left bundle. Theophylline should be considered in patients with painful LBBB in whom sinus node suppression has been unsuccessful and invasive management with permanent pacemaker is not desired.

PO-04-017 'LEFT' BROKEN AFTER EXERCISE: A CASE OF PAINFUL LBBB SYNDROME SUCCESSFULLY TREATED WITH LEFT BUNDLE BRANCH AREA PACING

The leading causes of new-onset left bundle branch block (LBBB) include coronary artery disease, hypertension, and cardiomyopathies. However, when the LBBB occurs in the absence of ischemia, in a rate-dependent manner, usually with exertion, it constitutes a painful left bundle branch block. Although there are multiple case reports of this entity, the mechanism, pathophysiology, and treatment are not well defined. We intend to raise awareness of this syndrome and highlight our unique treatment approach. NA A 57-year-old male presented to the cardiology clinic with exertional chest pain and palpitations. He underwent an exercise ECG test, surprisingly on stage 2 of Bruce protocol, at around a heart rate of 116 bpm; he started developing LBBB on every other beat. At a heart rate of 125 bpm, he developed persistent LBBB associated with similar symptoms, both of which persisted in the recovery phase (Figure 1). His Echocardiogram was normal. Invasive coronary angiography revealed normal coronaries. Previous case reports have shown that cardiac rehabilitation helps to delay the onset of LBBB to a higher heart rate; however, he opted for pacemaker implantation as he had severe exercise limitations. He underwent a biventricular-implantable pacemaker with right atrial, left bundle branch area, and coronary sinus (CS) left ventricular (LV) leads. The pacemaker was programmed DDD60 with a rate adaptive AV interval with a start rate of 80 bpm. This would enable the LBB area pacing above a heart rate of 80 bpm. Within one week of implantation, the patient had a complete resolution of his symptoms. A cardiopulmonary exercise test to assess VO2 with pacing programmed off and then on is scheduled as part of the follow-up. The symptoms of the painful LBBB syndrome can be quite severe, resulting in physical and psychological debilitation. Treatment with a physical exercise regimen has been successful as it delays the LBBB onset to a higher heart rate. However, the patient loses the benefit once they stop exercising. A definitive solution is a pacemaker; there are multiple case reports of His bundle and right ventricular pacing, which successfully treated this syndrome. In this case, we used a unique approach of pacing just the LBBB area; in addition, a CS LV lead was placed, which could be used for an earlier activation of the LV if the patient needs that in the future.

539 Frequency related left bundle branch block as cause of chest pain: ‘painful LBBB syndrome’

Abstract Aims A 47-years-old man presented to our cardiology ambulatory due to sudden chest pains, mainly on exertion. His only relevant cardiovascular risk factor was a familiarity for coronaropathy. In 2013 he had undergone a coronary angiography which was negative for stenotic lesions. Since then he was treated with beta-blockers and Ivabradine with mild improvement of the pain. Methods and results While his previous Holter-ECG reported sinus rhythm [heart rate (HR) 60 b.p.m.] and no alterations of atrioventricular nor of interventricular conduction, his ECG during his examination in our ambulatory showed sinus rhythm (HR 80 b.p.m.), normal atrioventricular conduction but presence of complete left bundle branch block. We therefore performed an ergometric test. His baseline ECG (HR around 65 b.p.m.), at the start of the test, showed no left bundle branch block and the QRS complex was narrow. During the test, at the heart rate of around 85 b.p.m., the ECG showed a complete left bundle branch block. At the same time the patient complained of typical chest pain. The ergometric test was submaximal as it was stopped at the beginning of the third Bruce stage due to the patient’s chest pain. No ST segment alterations were found. During the recovery phase, we noted that the left bundle branch block disappeared when the heart rate was below 75 b.p.m. A new coronary angiography was performed and again it showed no stenotic lesion. We therefore concluded our diagnostic workup and diagnosed a frequency related ‘painful left bundle branch block syndrome’. Conclusions ‘Painful left bundle branch block syndrome’ is defined as the presence of typical chest pain together with left bundle branch block, in the absence of signs of myocardial ischaemia. The pain improves once the conduction defect disappears. The mechanism of the syndrome is not known although it seems to be related to dyssynchrony of the myocardium. It may often be frequency related.

Painful Left Bundle Branch Block Syndrome Complicated by Iron-Overload Cardiomyopathy.

Painful left bundle branch block (LBBB) syndrome is a rare disease that presents as simultaneous chest pain and transient LBBB without myocardial ischemia. We diagnosed a 72-year-old Japanese man with painful LBBB syndrome complicated by iron-overload cardiomyopathy. Phlebotomy was initially performed to improve myocardial iron deposition and conductive disturbance. Ironically, his chest pain was fully improved by the completion of incessant LBBB and walk-through phenomenon. However, this case demonstrates a clinically significant therapeutic strategy for cardiomyopathy-induced painful LBBB syndrome. Due to the lack of treatment guidelines, individualized treatment is required for each case of painful LBBB.

CME: Left Bundle Branch Block and Painful Left Bundle Branch Block Syndrome

CME: Left Bundle Branch Block and Painful Left Bundle Branch Block Syndrome Abstract. Left bundle branch block (LBBB) is the electrocardiographic correlate of a pathologic transmission of the electrical signals in the myocardium which can lead to a dyssynchronous left ventricular activation and thus to an inefficient contraction of the ventricles. It is usually the expression of an underlying cardiopathy and represents an independent risk factor of cardiovascular mortality, therefore further examination is indicated in each case. Besides the treatment of an underlying disease, a specific therapy has been available since the introduction of cardiac resynchronization therapy (CRT). A rarer phenomenon is the painful left bundle branch block in structurally healthy hearts.

CME/Answers: Left Bundle Branch Block and Painful Left Bundle Branch Block Syndrome

CME/Answers: Left Bundle Branch Block and Painful Left Bundle Branch Block Syndrome Abstract. Left bundle branch block (LBBB) is the electrocardiographic correlate of a pathologic transmission of the electrical signals in the myocardium which can lead to a dyssynchronous left ventricular activation and thus to an inefficient contraction of the ventricles. It is usually the expression of an underlying cardiopathy and represents an independent risk factor of cardiovascular mortality, therefore further examination is indicated in each case. Besides the treatment of an underlying disease, a specific therapy has been available since the introduction of cardiac resynchronization therapy (CRT). A rarer phenomenon is the painful left bundle branch block in structurally healthy hearts.

Painful left bundle branch block: A syndrome with a particular clinical significance

The development of angina in the setting of new-onset left bundle branch block (LBBB) that resolves at the same time with the disappearance of LBBB, without coexistent myocardial ischemia, denotes the painful LBBB syndrome. In this illustrative case report we describe a young male patient with painful LBBB syndrome. The LBBB was rate-dependent occurring during exercise and the patient was successfully treated with bisoprolol. We also provide a concise review of the literature and we briefly discuss the diagnosis and management of this clinical entity.<Learning objective: Painful left bundle branch block syndrome is a rare clinical entity, that is possibly underdiagnosed. The exclusion of coronary artery disease in a patient with angina pectoris occurring simultaneously with the development of left bundle branch block should raise the suspicion of this syndrome.>

Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis

A 49-year-old woman presented with exercise-induced chest discomfort during long-distance running that was occasionally present during rest. Significant coronary artery disease was excluded and a diagnosis of “painful left bundle branch block (LBBB) syndrome” was made after correlation of LBBB aberrancy with symptoms during Holter monitoring. The patient underwent confirmatory testing consisting of rapid atrial pacing below and above 130 beats per minute, the rate cut-off for LBBB manifestation. His bundle pacing implantation was performed resulting in both non-selective and selective morphologies depending on output, both of which manifested with a painless narrow QRS regardless of rate. She was rendered completely pain free during long-distance running and remains so 6-months later. Her pain at rest, now thought to be due to severe anxiety secondary to her painful LBBB, has also subsided. Exercise-induced, painful LBBB is a rare phenomenon that manifests as chest discomfort when LBBB is present. This disease is frequently misdiagnosed as coronary angina, has limited medical treatment options, and can be disabling. HBP is an attractive treatment for this syndrome in an effort to avoid electromechanical dyssynchrony, the presumed mechanism of discomfort. This case report adds to the growing literature of painful LBBB syndrome and its effective treatment with HBP, with the added caveat that it can present with persistent symptoms at rest, in the setting of enhanced anxiety. HBP should be considered early on in the treatment of such patients.

Persistent Exertional Chest Pain in a Marathon Runner: Exercise-induced, Painful, Left Bundle Branch Block Syndrome Treated With His-Bundle Pacing

A 49-year-old woman presented with exercise-induced chest discomfort during long-distance running that was occasionally present during rest. Significant coronary artery disease was excluded and a diagnosis of “painful left bundle branch block (LBBB) syndrome” was made after correlation of LBBB aberrancy with symptoms during Holter monitoring. The patient underwent confirmatory testing consisting of rapid atrial pacing below and above 130 beats per minute, the rate cut-off for LBBB manifestation. His bundle pacing implantation was performed resulting in both non-selective and selective morphologies depending on output, both of which manifested with a painless narrow QRS regardless of rate. She was rendered completely pain free during long-distance running and remains so 6-months later. Her pain at rest, now thought to be due to severe anxiety secondary to her painful LBBB, has also subsided. Exercise-induced, painful LBBB is a rare phenomenon that manifests as chest discomfort when LBBB is present. This disease is frequently misdiagnosed as coronary angina, has limited medical treatment options, and can be disabling. HBP is an attractive treatment for this syndrome in an effort to avoid electromechanical dyssynchrony, the presumed mechanism of discomfort. This case report adds to the growing literature of painful LBBB syndrome and its effective treatment with HBP, with the added caveat that it can present with persistent symptoms at rest, in the setting of enhanced anxiety. HBP should be considered early on in the treatment of such patients.

Painful left bundle branch block syndrome treated with his bundle pacing

This is a case report of a patient with painful LBBB Syndrome that responded favorably to His Bundle Pacing. This syndrome is largely under recognized despite 50 reports in the literature over the last 60 years. Both diagnosis and treatment are not well defined and represent a major challenge in patients with this entity. Right ventricular pacing has been attempted with inconsistent efficacy outcomes. We report for the first-time complete resolution of chest pain with His bundle pacing. HBP provides a promising alternative pacing option that might provide symptom resolution to patients with a painful LBBB syndrome.

Painful left bundle branch block syndrome: Clinical and electrocardiographic features and further directions for evaluation and treatment

Painful left bundle branch block (LBBB) is a rarely diagnosed chest pain syndrome caused by intermittent LBBB in the absence of myocardial ischemia. Its prevalence, mechanism, detailed electrocardiographic (ECG) features, and effective treatments are not well described. The purpose of this study was to characterize clinical and ECG features of patients with painful LBBB syndrome with respect to the LBBB ECG morphology (in particular QRS axis and the precordial S/T wave ratio), clarify diagnostic criteria and possible mechanisms, and provide directions for further evaluation and treatment. We analyzed clinical (n = 50) and ECG (n = 15) features of patients with painful LBBB syndrome (4 patients in our practice and 46 cases identified in the literature). All 15 ECGs of patients with painful LBBB syndrome had an inferior QRS axis and a very low (<1.8) precordial S/T wave ratio, which was consistent with the "new LBBB" pattern. We report a case of painful LBBB syndrome coexisting with coronary artery disease. Right ventricular apical pacing resolved intractable chest pain in 1 case of painful LBBB. Painful LBBB ECG morphology within seconds/minutes of its onset is consistent with the new LBBB pattern with a very low (<1.8) precordial S/T wave ratio and inferior QRS axis. Painful LBBB syndrome can coexist with coronary artery disease, complicating the assessment of chest pain in the setting of LBBB. An electrophysiology study might be considered to investigate whether changing ventricular activation pattern by pacing provides consistent pain control and to select the most effective pacing configuration.

Painful left bundle branch block detected during dobutamine stress echocardiography

We report on the observation, in a 50-year-old woman undergoing dobutamine stress echocardiography, of the simultaneous onset of complete left bundle branch block and anginal chest pain, unaccompanied by any abnormality of left ventricular segmental contraction or wall thickening. Further etiologic investigations, in particular for coronary artery disease, proved negative. This observation is discussed in the context of a literature review. (J Am Soc Echocardiogr 2002;15:1405-8.)

Long-term outcome of painful left bundle branch block

Thus, painful LBBB has a good prognosis concerning long-term myocardial infarction or mortality. Progression to a permanent LBBB with disappearance of chest pain is frequent. Clinical surveillance is recommended because complete atrioventricular block and depression of left ventricular systolic function can be observed in rare cases.

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.