Factores asociados al bloqueo de rama derecha en adultos mayores / Factors associated with right bundle branch block in older adults

RESUMEN Introducción: Existe poca literatura sobre la asociación entre el bloqueo de rama derecha y factores de riesgo como la hipertensión y la diabetes en pacientes de Latinoamérica y Perú. Objetivo: Determinar los factores asociados al bloqueo de rama derecha en adultos mayores. Métodos: Estudio transversal que incluyó 376 pacientes adultos mayores atendidos en el Hospital Almanzor Aguinaga Asenjo, Lambayeque-Perú. La variable dependiente fue la presencia de bloqueo de rama derecha y las variables independientes fueron edad, sexo, antecedente de hipertensión arterial y diabetes. Se estimaron razones de prevalencia e intervalos de confianza al 95 %. Resultados: De 376 pacientes, la mayoría eran varones (55,9 %), la edad media fue de 75,6 años, el 11,4 % tuvo antecedente de hipertensión y el 9 % era diabético. El 41 % tuvo diagnóstico de bloqueo de rama derecha. En la regresión múltiple; el sexo femenino (RP=1,53, IC 95 %: 1,21 - 1,95), antecedente de hipertensión (RP=1,55; IC 95 %: 1,21 - 2,00) y diabetes mellitus (RP=1,49, IC 95 %: 1,12 - 2,00) se asociaron de forma positiva a presentar bloqueo de rama derecha. El modelo anidado seleccionó las variables: sexo femenino (RP=1,54, IC 95 %: 1,21 - 1,96) y antecedente de hipertensión arterial (RP=1,61, IC 95 %: 1,25 - 2,08). Conclusión: El sexo femenino, antecedente de hipertensión arterial y de diabetes mellitus se asocian positivamente a presentar bloqueo de rama derecha.

ABSTRACT Introduction: There is little literature on the association between right bundle branch block and risk factors such as hypertension and diabetes in patients in Latin America and Peru. Objective: To determine the factors associated with right bundle branch block in older adults. Methods: Analytical cross-sectional study completed by 376 elderly patients treated at Almanzor Aguinaga Asenjo Hospital, Lambayeque-Peru. The dependent variable was the presence of right bundle branch block, and the independent variables were age, sex, history of hypertension, and diabetes. Prevalence ratios and 95 % confidence intervals were estimated. Results: Of 376 patients, the majority were male (55,9 %), the mean age was 75,6 years, 11,4 % had a history of hypertension and 9 % were diabetic; 41 % had a diagnosis of right bundle branch block. In simple regression, the frequency of right bundle branch block was 56 % (PR= 1,56; 95 % CI: 1,22-1,99), 65 % (PR=1,65; 95 % CI: 1,26 - 2,15) and 59 % (PR= 1,59; CI 95 %: 1,18 - 2,14) higher in women, hypertensive and diabetics; respectively. In the multiple regression; female sex (PR= 1,53; 95 % CI: 1,21 - 1,95), history of hypertension (PR= 1,55; 95 % CI: 1,21 - 2,00) and diabetes mellitus (PR= 1,49; 95 % CI: 1,12 - 2,00) were positively associated with right bundle branch block. The nested model selected the variables: female sex (PR= 1,54; 95 % CI: 1,21 - 1,96) and history of arterial hypertension (PR= 1,61; 95 % CI: 1,25 - 2,08). Conclusion: Female sex, history of arterial hypertension and diabetes mellitus were positively associated with presenting right bundle branch block in older adults.

Manejo de la insuficiencia cardiaca con estimulación hisiana en bloqueo de rama derecha: reporte de caso / Management of heart failure with His bundle pacing in right bundle branch block: case report

Resumen La terapia de resincronización cardiaca mediante estimulación hisiana ha demostrado ser efectiva en pacientes con bloqueo de rama izquierda del haz de His e insuficiencia cardiaca. Paciente masculino, con 47 años de edad, con insuficiencia cardiaca, fracción de expulsión del 17% y miocardio dilatada idiopática, electrocardiograma en ritmo sinusal, bloqueo auriculoventricular de 1.er grado, intervalo PR 400 ms, bloqueo completo de rama derecha del haz de His, bloqueo del fascículo anterior de la rama izquierda del haz de His, duración del QRS 200 ms. Se decidió realizar estimulación selectiva del haz de His. La resincronización cardiaca biventricular convencional en pacientes con presencia de bloqueo completo de la rama derecha del haz de His no está indicada debido a la pobre respuesta al tratamiento. La estimulación hisiana permite reclutar la rama bloqueada y reestablecer la conducción a través de ella, de tal forma que, en ausencia de necrosis, se logre sincronía biventricular. En el caso presentado el reclutamiento de la rama derecha mediante estimulación hisiana se reflejó en el restablecimiento de la sincronía biventricular, medida por rastreo de marcas (speckle tracking) e incremento significativo de la fracción de expulsión del ventrículo izquierdo del 17 al 36.6%, con un incremento absoluto del 19.6%.

Abstract Cardiac resynchronization therapy has proven to be an effective therapy in patients with left bundle branch block and heart failure. Male, 47 years old, heart failure with a left ventricle ejection fraction of 17%, idiopathic heart failure. ECG with sinus rhythm, 1st degree AV block, PR 400 ms, complete right bundle branch block, anterior hemi-fascicle of the left bundle of His, and QRS duration 200 ms. We decided to perform a selective His bundle pacing. In patients with right bundle branch block the biventricular cardiac resynchronization is not indicated due to low treatment response. His bundle pacing allows recruiting the blocked branch and restoring conduction throughout it, therefore, in the absence of necrosis the biventricular synchrony is achieved. We presented a case of His bundle pacing with recruitment of the right bundle branch, which reestablish biventricular synchrony measured by speckle tracking, and with a significant increase of the left ventricle ejection fraction from 17 to 36.6%, with an absolute increase of 19.6%.

Complex uninterpretable electrocardiogram and syncope

Electrocardiogram(ECG) is an essential component as diagnostic modalities in cardiovascular diseases. A wide spectrum of diseases can be diagnosed by ECG. Conduction disturbances manifest in ECG with characteristics manner. Sometimes these manifestations are not interpretable with the current concept of cardiovascular physiology. Here I have reported such an interesting ECG which is complex and difficult to interpret

Hallazgos clínicos y electrocardiográficos en pacientes pediátricos con comunicación interauricular / Clinical and electrocardiographic findings in pediatric patients with atrial septal defects

Introducción: La comunicación interauricular (CIA) es una cardiopatía congénita frecuente, cuyo diagnóstico es difícil en pacientes paucisintomáticos. Sin tratamiento, puede complicarse con insuficiencia cardiaca, arritmias e hipertensión pulmonar. El electrocardiograma puede proporcionar indicios de esta cardiopatía. Objetivo: Describir los hallazgos clínicos y electrocardiográficos de pacientes portadores de CIA. Materiales y Métodos: Trabajo retrospectivo, de pacientes menores de 18 años, evaluados cardiológicamente de enero 2008 a diciembre de 2013. Se describen las variables electrocardiográficas y semiológicas sugestivas de CIA. Resultados: Hubo 77 pacientes con CIA. Los motivos de consulta más frecuentes entre los pacientes con CIA fueron el soplo cardiaco, el síndrome de Down y la disnea. En el examen físico de los pacientes con CIA: soplo sistólico en 69% y R2 desdoblado en 56%. En el electrocardiograma, los pacientes tuvieron QRS de 79 ms, eje eléctrico desviado hacia la derecha, BIRD y notch. Los criterios de sobrecarga ventricular derecha (SVD) más frecuentes fueron la onda S profunda en V6 y la onda R alta en V1. La auscultación de un R2 desdoblado en el examen físico, así como la SVD y el patrón notch fueron los hallazgos más frecuentes en pacientes con CIA. Conclusión: el electrocardiograma constituye una herramienta válida en la evaluación de pacientes con sospecha de CIA pero precisa de la combinación de hallazgos clínicos para llegar al diagnóstico.

Introduction: Atrial Septal Defect (ASD) is a frequent congenital heart disease, the diagnosis of which is difficult in paucisymptomatic patients. Without treatment, it can lead to heart failure, arrhythmias and pulmonary hypertension. The electrocardiogram may provide evidence of this condition. Objective: To describe the clinical and electrocardiographic findings of patients with ASD. Materials and Methods: This was a retrospective study of patients under age 18 who underwent cardiac evaluation from January 2008 to December 2013. The electrocardiographic and clinical finding variables suggestive of ASD are described. Results: There were 77 patients with ASD. The most frequent reasons for consultation among patients with ASD were heart murmur, Down syndrome and dyspnea. Findings on physical examination of patients with ASD were: systolic murmur in 69% and S2 split in 56%. On the electrocardiogram, the patients had QRS of 79 ms, electric axis deviated to the right, Incomplete Right Bundle Branch and notch pattern. The most frequent right ventricular volume overload (RVVO) criteria were the deep S wave in V6 and the high R wave in V1. Auscultation of a split S2 on the physical examination, as well as the RVVO and the notch pattern were the most frequent findings in patients with ASD. Conclusion: the electrocardiogram is a valid tool in the evaluation of patients with suspected ASD but requires the combination of clinical findings to reach the diagnosis.

Association of Newly Developed Right Bundle Branch Block with Graft Rejection Following Heart Transplantation

PURPOSE: We aimed to examine associations between right bundle branch block (RBBB) following heart transplantation (HT) and graft rejection. MATERIALS AND METHODS: We investigated 51 patients who underwent endomyocardial biopsies, electrocardiogram, right-side cardiac catheterization, and echocardiography at 1 month and 1 year after HT. We classified patients into four groups according to the development of RBBB, based on electrocardiogram at 1 month and 1 year: 1) sustained RBBB, 2) disappeared RBBB, 3) newly developed RBBB, and 4) sustained non-RBBB. The RBBB was defined as an RSR' pattern in V1 with a QRS duration ≥100 ms on electrocardiogram. RESULTS: The newly developed RBBB group (n=13, 25.5%) had a higher rate of new onset graft rejection (from grade 0 to grade ≥1R, 30.8% vs. 10.0% vs. 21.4%, p=0.042) at 1 year, compared with sustained RBBB (n=10, 19.6%) and sustained non-RBBB group (n=28, 54.9%). In contrast, the incidence of resolved graft rejection (from grade ≥1R to grade 0) was higher in the sustained RBBB group than the newly developed RBBB and sustained non-RBBB groups (70.0% vs. 7.7% vs. 25.0%, p=0.042). Left atrial volume index was significantly higher in the newly developed RBBB group than the sustained RBBB and sustained non-RBBB groups (60.6±25.9 mL/m2 vs. 36.0±11.0 mL/m2 vs. 38.4±18.1 mL/m2, p=0.003). CONCLUSION: Close monitoring for new development of RBBB at 1 year after HT, which was associated with a higher incidence of new onset graft rejection, may be helpful to identify high risk patients for graft rejection.

A Case of Acute Total Obstruction of the Left Main Coronary Artery Presenting with Atypical Momentary Electrocardiogram Changes

Acute total obstruction of the left main coronary artery (LMCA) is a serious emergency condition requiring prompt diagnosis and treatment. Unless properly treated, it will likely progress to cardiogenic shock and a high mortality rate. We report a case of acute LMCA total obstruction presenting with atypical momentary electrocardiogram (ECG) changes including right bundle branch block with left axis deviation, and ST-segment elevation in aVR and aVL. We focus on the unusual ECG changes associated with LMCA obstruction which should be noted in order to ensure revascularization without delay, especially when this condition is accompanied by cardiogenic shock.

Trastornos de conducción ventricular y miocardio inactivable / Ventricular conduction disorder in presence of dead myocardium

Un bloqueo de rama izquierda (BRIHH) de grado avanzado, i.e. con fenómeno de "salto de onda" extenso, hace que la activación septal anormal de origen a fuerzas electromotrices de mayor duración y magnitud respecto a las normales. Por eso se establece una preponderancia eléctrica septal respecto a las paredes libres ventriculares. La coexistencia de una zona de miocardio inactivable antero-septal con un BRIHH de grado avanzado hace que el "salto de onda" comience en porciones postero-septales inferiores. Por ende, los electrodos izquierdos externos ven alejarse los primeros frentes de la activación ventricular y registran ondas Q. La presencia de miocardio inactivable en la pared libre ventricular izquierda permite al electrodo externo correspondiente registrar la morfología del complejo intraventricular homolateral: R¯S. Un BRIHH de grado intermedio da origen a un "salto de onda" limitado de derecha a izquierda. Cuando dicho bloqueo se asocia a la presencia de miocardio inactivable septal, se reducen las manifestaciones del bloqueo izquierdo pero están presentes las de la necrosis: pérdida de la manifestación del primer vector septal derecho y registro de ondas Q en las derivaciones izquierdas. A causa de un bloqueo de rama derecha (BRDHH) de grado avanzado, con "salto de onda" extenso, también se originan fuerzas electromotrices septales predomi nantes. La coexistencia de una zona de miocardio inactivable anteroseptal con un BRDHH de grado avanzado hace que el "salto de onda" de izquierda a derecha comience en porciones postero-septales bajas. Así los electrodos de las derivaciones transicionales ven alejarse los primeros frentes del "salto de onda" y registran: ondas Q. Una zona inactivable parietal derecha, transmural, permite a los electrodos externos correspondientes registrar la morfología polifásica del complejo intra-ventricular homolateral. Un BRDHH de grado intermedio, asociado a necrosis antero-septal, se caracteriza por reducción de los signos de bloqueo y presencia de ondas Q en las derivaciones precordiales derechas y transicionales.

In the presence of an advanced degree left bundle branch block (LBBB) with an extensive "Jumping wave" phenomenon, the septal activation abnormally spreading originates septal electromotive forces of greater duration and consequently more important than normal ones. The coexistence of an inactive anteroseptal myocardium with an advanced degree block causes the phenomenon of "Jumping wave" begins in postero-septal regions. Therefore the external left electrodes see the first ventricular activation fronts moving away and register Q waves. The presence of transmural inactive myocardium in the free left ventricular wall permits the corresponding external electrodes to record the morphology of the ipsilateral intraventricular complex: R¯S. An intermediate degree LBBB produces a limited right to left "Jumping wave" phenomenon. When it is associated to septal inactive myocardium, the electrical manifestations of left block are reduced, but those of myocardial necrosis persist: loss of the manifestation of first right septal vector and presence of Q waves in left leads. Because of an advanced degree right bundle branch block (RBBB) with an extensive "Jumping wave" phenomenon, electromotive septal forces of greater duration and consequently more important than normal ones, are originated also. The coexistence of inactive antero-septal myocardium with an advanced degree RBBB causes the phenomenon of "Jumping wave" begins in inferior postero-septal regions. Therefore, the transitional leads see the first fronts of the said phenomenon moving away and register Q waves. The presence of inactive transmural right parietal myocardium permits the corresponding external electrodes to record the morphology of the ipsilateral polyphasic intraventricular complex. An intermediate degree RBBB, associated to antero-septal necrosis, is characterized by the reduction of the electrocardiographic signs of the said block and the presence of Q waves in the right precordial and transitional leads.

In-hospital outcome in patients with ST elevation myocardial infarction and right bundle branch block: A sub-study from RENASICA II, a national multicenter registry / Evolución intrahospitalaria en pacientes con infarto agudo del miocardio con elevación del segmento ST y bloqueo de rama derecha: Sub-estudio de RENASICA II, un registro nacional multicéntrico

Objective: Compare in-hospital outcome in patients with ST-elevation myocardial infarction with right versus left bundle branch block. Methods: RENASICA II, a national mexican registry enrolled 8098 patients with final diagnosis of acute coronary syndrome secondary to ischemic heart disease. In 4555 STEMI patients, 545 had bundle branch block, 318 (58.3%) with right and 225 patients with left (41.6%). Both groups were compared in terms of in-hospital outcome through major cardiovascular adverse events; (cardiovascular death, recurrent ischemia and reinfarction). Multivariable analysis was performed to identify in-hospital mortality risk among right and left bundle branch block patients. Results: There were not statistical differences in both groups regarding baseline characteristics, time of ischemia, myocardial infarction location, ventricular dysfunction and reperfusion strategies. In-hospital outcome in bundle branch block group was characterized by a high incidence of major cardiovascular adverse events with a trend to higher mortality in patients with right bundle branch block (OR 1.70, CI 1.19 - 2.42, p < 0.003), compared to left bundle branch block patients. Conclusion: In this sub-study right bundle branch block accompanying ST-elevation myocardial infarction of any location at emergency room presentation was an independent predictor of high in-hospital mortality.

Objetivo: Comparar la evolución hospitalaria en pacientes con infarto agudo del miocardio con bloqueo de rama derecha versus bloqueo de rama izquierda. Método: El Registro Nacional de Síndromes Coronarios Agudos II, incluyó 8098 pacientes con síndrome coronario agudo, de los cuales 4555 corresponden a infarto con elevación del segmento ST. De ellos, se demostró en 545 bloqueo de rama: 318 (58.3%) tuvieron bloqueo de rama derecha y 227 (41.6%) bloqueo de rama izquierda. Fueron comparados en términos de mortalidad hospitalaria y eventos cardiovasculares mayores adversos. Se realizó un análisis multivariado para identificar mortalidad hospitalaria a través de eventos mayores entre pacientes con ambos bloqueos de rama. Resultados: No hubo deferencia estadísticamente significativa en ambos grupos en relación con características basales, tiempo de isquemia, localización del infarto, disfunción ventricular o estrategia de reperfusión utilizada. Los pacientes con infarto agudo del miocardio de cualquier localización y bloqueo de rama derecha tuvieron mayor tendencia para mortalidad hospitalaria y eventos cardiovasculares mayores (OR 1.70, IC 1.19-2.42, p < 0.003) vs. pacientes con bloqueo de rama izquierda. Conclusión: En el infarto agudo del miocardio con elevación del segmento ST, el bloqueo de rama derecha fue un predictor independiente de alta mortalidad hospitalaria.

Comparison of head-chest lead and routine lead electrocardiograms of right bundle branch block / 第二军医大学学报

Objective: To explore the rule of voltage change in the reference point of electrocardiograms ( ECG). Methods: The r and R′ waves on the head-chest lead and routine lead ECGs in 21 patients with right bundle branch block in whole synchronization were compared, and the correlation of voltage change in reference point with the direction of cardiac muscular stimulation of ECGs was analyzed. Results: The swing of wave r in head-chest leads was significantly higher than that of routine leads([0.16±0.19] vs [0.11±0.13] mV, P<0.01), and the swing of wave R′ in head-chest leads was significantly lower than that of the routine leads( [0.25±0.21] vs [0.35±0.23] mV, P<0.01). Conclusion: Voltage change in reference point of ECG varies with the direction of cardiac muscular stimulation.

Cardiac complication secondary to jugular catheter insertion in a renal failure patient

Central venous catheterisation is a common procedure performed for emergency dialysis. It is usually carried out without any cardiac monitoring. Cardiac arrhythmias with associated conduction blocks are rare complications. The underlying pathogenesis is trauma to the endocardium by the guide wire or catheter. It occurs more frequently in patients with acute renal failure and azotaemia than patients with established end stage renal disease. Disturbances in acid base balance and electrolyte abnormalities are contributing factors. Fortunately, most are benign but occasionally can lead to potentially fatal arrhythmias. We report a case of a 46-year-old lady with end stage renal failure secondary to diabetes mellitus who developed runs of transient ventricular ectopics and right bundle branch block during internal jugular catheterisation. This spontaneously resolved 12 hours later.

Estudo de perfusão miocárdica em portadores de bloqueio de ramo direito / Myocardial perfusion study in patients with right bundle branch block

PURPOSE: To evaluate the sensitivity and specificity of myocardial perfusion scintigraphy in the detection of coronary artery disease in patients with right bundle branch block (RBBB). METHODS: Thirty one patients (24 male, 62.3 +/- 10.5 years) with RBBB, submitted to myocardial perfusion scintigraphy associated with exercise (n = 7) or dipyridamole (n = 24) and previous cinecoronariography were studied retrospectively. Left ventricle scintigraphic image was divided in three segments corresponding to the three main epicardic coronary territories in a total of 93 segments. Cineangiographic and scintigraphic data were then compared according to the different artery territories. RESULTS: Twenty three patients had significant lesions (> or = 60) in one or more coronary arteries and eight had no obstruction. Forty nine segments were irrigated by normal coronary arteries and 44 were related to arteries that had significant lesions. Twenty out of twenty three patients showed alterations in perfusion (sensitivity = 87). All patients without coronary obstructions showed normal perfusion scintigraphy (specificity = 100). One of the segments perfused by normal coronaries showed abnormal scintigraphy. Scintigraphy showed perfusion defects in 29 out of 44 segments with coronary obstructions. Sensitivity and specificity of the method for each arterial territory were 72and 100(left descending coronary artery), 67and 94(right coronary artery), 55and 100(circunflex coronary artery), respectively. CONCLUSION: The presence of RBBB does not modify the sensitivity and specificity of the method in the detection of coronary artery disease.

Histopatologia da porção trabecular do ramo direito do feixe de His em chagásicos crônicos com bloqueio de ramo direito / Histopathology of the Trabecular Segment of the Right Bundle Branch in Chronic Chagasic Patients with Right Bundle Branch Block

PURPOSE--To evaluate possible morphological changes in chronic chagasic of the right bundle trabecular branch (RB) with right branch block (RBB) and to draw clinicopathological correlations. METHODS--Eight RBB chronic chagasic septo-marginal trabeculae (SMT) (group A), six left branch block (LBB) chagasic SMT (group B) and six SMT from non-chagasics with no heart disease (group C) were analyzed. Every SMT was completely embedded in paraffin, sub-serially sectioned to the end of the paraffin-block and the sections were processed for pathological study. RESULTS--Right bundle branch trabecular segment mononuclear infiltrate and/or fibrosis were found for 87.5 (7/8) of group A, 50 por cento (3/6) of group B and 16.6 por cento (1/6) of group C. Moderate mononuclear infiltrate and fibrosis were noted respectively for 3 and 1 cases, from group A. For the remaining group A cases and for all the group B and C cases the mononuclear infiltrate and fibrosis were slight. CONCLUSION--The frequency and degree of RB lesions might explain some of RBB. On the other hand, the absence of lesions in one case RBB and the slight degree of RB lesions in chagasics with LBB and in one non-chagasic case indicate that sometimes it is not possible to establish electrocardiographic-pathological correlations after TSM histological examination