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Bundle Branch Blocks And/Or Hemiblocks Complicating Acute Myocardial Ischemia Or Infarction

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Bundle Branch Blocks And/Or Hemiblocks Complicating Acute Myocardial Ischemia Or Infarction Journal of Interventional Cardiac Electrophysiology https://doi.org/10.1007/s10840-018-0430-3 Bundle branch blocks and/or hemiblocks complicating acute myocardial ischemia or infarction Samuel Lévy1 Received: 23 May 2018 /Accepted: 24 July 2018 # Springer Science+Business Media, LLC, part of Springer Nature 2018 Abstract 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. Keywords Right bundle branch block . Left anterior hemiblock . Left posterior hemiblock . Bifascicular block . Angina pectoris . Atrioventricular block 1 Introduction anatomical lesions. However, Rosenbaum and colleagues in 1968 adopted the concept of a bifascicular system in their Despite the bulk of evidence both anatomical and histological description of the electrocardiographic features of what supporting the possible existence of three fascicles in the left they called “hemiblocks” [4, 5] and used since as a practical branch of the His bundle as described in anatomical and the teaching tool. The hemiblocks refer to delay or block in the historical reports, the “bifascicular concept” has gained popu- antero-superior fascicle of the left branch of the His bundle larity [1–3]. The main left branch subdivides into an antero- (LAH) or to delay or block in the postero-inferior fascicle superior branch, a postero-inferior branch and possibly a sep- (LPH) although at times the block may be “focal” corre- tal branch. It should be emphasized that the anatomy of the sponding not to conduction delay or block in the fascicles left branch of the His bundle is more complex than previ- of the left branch but to conduction delay of the impulse in ously thought and it is hypothetical to establish a relation the myocardial territory of one or the other fascicle. Some between the electrocardiographic aspects and the possible authors prefer to use the term “fascicular blocks” instead of hemiblocks. But hemiblocks refer to ECG characteristics and not to possible lesions in the left bundle branch system. * Samuel Lévy In this review, we will use the nomenclature proposed by [email protected] Rosenbaum and his school [3–5] in their remarkable efforts “ ” 1 to promote the bifascicular concept of the left branch Aix-Marseille Université, School of Medicine, 2, Place Delibes, – 13008 Marseille, France system. Castellanos et al. [6 10] adopted their ECG J Interv Card Electrophysiol definitions with minor modifications in their study of include [1] right axis deviation (≥ 100°), (2) S1Q3 pattern hemiblocks in acute myocardial infarction (MI). in the limb leads, (3) QRS duration ≤ 110 ms, (4) rS The LAH and the LPH may be isolated or most of the morphology in I and aVL, and (5) qR pattern in II, III, times associated with right bundle branch block (RBBB). VF. The diagnosis should exclude other causes of right Such conduction disturbances may be associated with cor- axis deviation such as right ventricular hypertrophy, ver- onary artery disease (CAD) which is the most common tical heart in slender subjects, asthma, chronic obstructive underlying heart disease and may complicate the course of pulmonary disease and mitral stenosis. Left posterior an acute MI. The other common etiologies of conduction hemiblock with RBBB complicating an acute inferior disturbances include the Chagas disease in South America wall MI is shown in Fig. 2. Note the Q waves in leads and the primary fibrosis of the conduction system called II, III and VF. Lenègre disease [11] or Lev disease [12]. As stated before, the “bifascicular system scheme” is a teaching tool to describe these ECG aspects which does reflect the complexity of the left branch anatomy or the disease that 2 Diagnostic ECG criteria for hemiblocks may affect its branches. Furthermore, a middle fascicule may be present and ECG aspects possibly affecting the left septal The electrocardiographic features of hemiblocks may vary fascicle have been reported [13, 14]. Interconnections be- according to the clinical context, to the serial ECG trac- tween the fascicles create a network what Fisher in this issue ings recorded in a given patient and to the anatomic mor- called a “spiderweb” [2]. phology of the patient. The ECG diagnosis for LAH in- cludes three criteria according to Rosenbaum [4, 5]and Elizarietal.[3]: [1] a left axis deviation (− 45° or more). 3 Pure left anterior hemiblock in coronary For Castellanos et al. [6–10] an axis deviation ranging artery disease patients from − 30 to − 90° particularly when there is evidence of normal axis in previous ECG recordings [6]. [2]A Among the studies we did under the guidance of Dr. small q wave in leads I and VL and a small r in leads Agustin Castellanos Jr., we looked at the angiographic II, III and VF. [3] A QRS widening by no more than aspects of pure (without BBB) LAH in patients with sig- 0.02 s and less than 0.11 in total duration. An ECG trac- nificant (at least one or more coronary obstruction ≥ 70%) ing of LAH with RBBB complicating an extensive ante- coronary artery lesions [8]. We reviewed the complete rior wall MI is shown in Fig. 1. Note that the RBBB did ECG files and clinical records of 283 consecutive patients not obscure the diagnosis of acute anterior MI. There are with significant CAD at coronary angiography (> 70% obviously other causes of left axis deviation such as left obstruction) and found “pure” LAHin20ofthem ventricular hypertrophy, horizontal heart or Wolff- (7.3%). The age range was 46–71 years with a mean of Parkinson-White syndrome in some accessory connection 61 years. There were 18 men and 2 women. ECG features locations. Therefore, the clinical context should be taken of old myocardial infarction (MI) were present in 10 pa- into account in ECG interpretation. tients. In all 20 patients (100%), a significant lesion of the Diagnostic criteria for LPH include both ECG criteria proximal left anterior descending (LAD) coronary artery and clinical setting exclusion criteria. The ECG criteria was present. [2] All 20 patients had severe CAD (2.5 Fig. 1 12-lead ECG recorded in a patient admitted for acute anterior wall myocardial infarction and right bundle branch block (RBBB) and left anterior hemiblock (LAH) J Interv Card Electrophysiol Fig. 2 ECG recorded in a patient with an acute inferior wall myocardial infarction and RBBB with left posterior hemiblock (LPH) vessels involved per patient). [3] Impairment of LV func- acute MI including the 12 lead ECGs and the hourly mon- tion was found in 14 patients (77%), 9 of them with a left itoring strips were reviewed. The criteria used to diagnose ventricular aneurysm. This study supports CAD as a ma- the presence of hemiblocks are those described by jor cause of pure LAH and the presence of significant Castellanos [6–10] who used the frontal plane of the lesion involving the LAD. vectorcardiogram to describe the LAH characteristics in inferior wall MI: “(1). inferior and rightward orientation of the initial 10 and 20 msec. vectors (inferior orientation 4 Bifascicular block complicating acute of the initial 40-msec vectors, suggests the presence of an myocardial infarction associated lateral infarction); (2) superior and leftward de- before the thrombolysis era viation of the maximal QRS vectors, (3) counterclockwise rotation of the QRS loop, and (4) inferior orientation of the The ECG diagnosis of RBBB and LAH in acute MI may ST-T loop. This results in the ECG in a qR pattern in lead I be sometimes difficult, and conversely, there are cases in and aVL, and rS complexes with positive T waves in leads which the LAH may obscure the diagnosis of myocardial II, III, and aVF. These criteria are still valid in the presence ” infarction. [3–7]. Such difficult cases are well described of complete RBBB . As mentioned before, the diagnosis elsewhere [3] and may require comparison with previous of LPH cannot be made on the basis of the ECG alone as ECG tracings, if available.
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