The deleterious effects of long-term right ventricular pacing necessitated the search for alternative pacing sites which could prevent or alleviate pacinginduced cardiomyopathy.Until recently,biventricular pacing(BiVP...The deleterious effects of long-term right ventricular pacing necessitated the search for alternative pacing sites which could prevent or alleviate pacinginduced cardiomyopathy.Until recently,biventricular pacing(BiVP)was the only modality which could mitigate or prevent pacing induced dysfunction.Further,BiVP could resynchronize the baseline electromechanical dssynchrony in heart failure and improve outcomes.However,the high non-response rate of around 20%-30%remains a major limitation.This non-response has been largely attributable to the direct non-physiological stimulation of the left ventricular myocardium bypassing the conduction system.To overcome this limitation,the concept of conduction system pacing(CSP)came up.Despite initial success of the first CSP via His bundle pacing(HBP),certain drawbacks including lead instability and dislodgements,steep learning curve and rapid battery depletion on many occasions prevented its widespread use for cardiac resynchronization therapy(CRT).Subsequently,CSP via left bundle branch-area pacing(LBBP)was developed in 2018,which over the last few years has shown efficacy comparable to BiVP-CRT in small observational studies.Further,its safety has also been well established and is largely free of the pitfalls of the HBP-CRT.In the recent metanalysis by Yasmin et al,comprising of 6 studies with 389 participants,LBBPCRT was superior to BiVP-CRT in terms of QRS duration,left ventricular ejection fraction,cardiac chamber dimensions,lead thresholds,and functional status amongst heart failure patients with left bundle branch block.However,there are important limitations of the study including the small overall numbers,inclusion of only a single small randomized controlled trial(RCT)and a small follow-up duration.Further,the entire study population analyzed was from China which makes generalizability a concern.Despite the concerns,the meta-analysis adds to the growing body of evidence demonstrating the efficacy of LBBP-CRT.At this stage,one must acknowledge that the fact that still our opinions on this technique are largely based on observational data and there is a dire need for larger RCTs to ascertain the position of LBBPCRT in management of heart failure patients with left bundle branch block.展开更多
Exercise-induced left bundle branch block(EI-LBBB)is infrequent phenomenon.We present two patients with angina pectoris who developed EI-LBBB during exercise tolerance test.The first patient with typical angina pector...Exercise-induced left bundle branch block(EI-LBBB)is infrequent phenomenon.We present two patients with angina pectoris who developed EI-LBBB during exercise tolerance test.The first patient with typical angina pectoris had significant obstructive coronary artery disease(CAD)requiring percutaneous coronary intervention of multiple lesions including placement of drug eluting stents.The second patient had atypical chest pain without signs of CAD at all.EI-LBBB occurred at a heart rate of 80 bpm and 141 bpm in the first and second patient,respectively.EI-LBBB remained visible through the test till the recovery period in the first patient at a heart rate of 83 bpm and disappeared at 96bpm in the second patient.Both patients with this infrequent phenomenon are discussed and the literature is reviewed.展开更多
The evaluation of wide QRS complex tachycardias (WCT)remains a common dilemma for clinicians.Numerous algorithms exist to aid in arriving at the correct diagnosis.Unfortunately,these algorithms are difficult to rememb...The evaluation of wide QRS complex tachycardias (WCT)remains a common dilemma for clinicians.Numerous algorithms exist to aid in arriving at the correct diagnosis.Unfortunately,these algorithms are difficult to remember,and overreliance on them may prevent cardiologists from understanding the mechanisms underlying these arrhythmias.One distinct subcategory of WCTs are those that present with a"typical"or"classic" left bundle branch block pattern.These tachycardias may be supraventricular or ventricular in origin and arise from functional or fixed aberrancy,bystander or participating atriofascicular pre-excitation,and bundle branch reentry.This review will describe these arrhythmias,illustrate their mechanisms,and discuss their clinical features and treatment strategies.展开更多
A 54-year-old female patient with congenital heart disease had a persistent complete left bundle branch block three months after closure by an Amplatzer ventricular septal defect occluder. Nine months later, the patie...A 54-year-old female patient with congenital heart disease had a persistent complete left bundle branch block three months after closure by an Amplatzer ventricular septal defect occluder. Nine months later, the patient suffered from chest distress, palpitation, and sweating at daily activities, and her 6-min walk distance decreased significantly (155 m). Her echocardiography showed increased left ventricular end-diastolic diameter with left ventricular ejection fraction of 37%. Her symptoms reduced significantly one week after received cardiac resynchronization therapy. She had no symptoms at daily activities, and her echo showed left ventricular ejection fraction of 46%and 53%. Moreover, left ventricular end-diastolic diameter decreased 6 and 10 months after cardiac resynchronization therapy, and 6-min walk dis-tance remarkably increased. This case demonstrated that persistent complete left bundle branch block for nine months after transcatheter closure with ventricular septal defect Amplatzer occluder could lead to left ventricular enlargement and a significant decrease in left ventricular systolic function. Cardiac resynchronization therapy decreased left ventricular end-diastolic diameter and increased left ventricular ejection fraction, thereby improving the patient’s heart functions.展开更多
Left bundle branch block(LBBB)causes a delay in left ventricular contraction with an unsynchronized ventricular systole.LBBB is an independent determinant of morbi-mortality mainly when associated with cardiomyopathy ...Left bundle branch block(LBBB)causes a delay in left ventricular contraction with an unsynchronized ventricular systole.LBBB is an independent determinant of morbi-mortality mainly when associated with cardiomyopathy and left ventricular dysfunction.[1] LBBB due to non-ischemic cardiomyopathy is considered non-reversible.Such irreversibility occurs because LBBB and cardiomyopathy act in a synergic manner in order to maintain both situations.However,there are a few reports in the literature showing that some patients have had an improvement in cardiac function with normalization of QRS and have experienced a reverse remodelling with pharmacological therapy only.[2–4]展开更多
Aims: Left bundle branch block (LBBB) is generally associated with a poorer prognosis in comparison to normal intraventricular conduction, but also in comparison to right bundle branch block which is generally conside...Aims: Left bundle branch block (LBBB) is generally associated with a poorer prognosis in comparison to normal intraventricular conduction, but also in comparison to right bundle branch block which is generally considered to be benign in the absence of an underlying cardiac disorder like congenital heart disease. In this paper we evaluate the presence of possible cardiovascular pathology in a group of nurses with a low level of cardiovascular risk factors and left bundle branch block (LBBB). Methods: During the period 2009-2013, 356 nurses (mean age: 32.6 ± 11 yr) were admitted to the department of Occupational Medicine of Second University of Naples. Of these, 13 had LBBB. The evaluation of these patients has included an electrocardiogram (ECG), echocardiography, 24-h ambulatory Holter monitoring (ECG Holter), and exercise testing. Subsequently, in patients with LBBB, multislice computed coronary angiography (MSCT) has been considered. Results and Conclusion: Only in one patient we found a significant stenosis in the middle tract of left anterior descending artery. Coronary artery disease remains difficult to diagnose in some ECG findings such as acquired LBBB. For this reason, a preventive diagnose with newly developed diagnostic methods such as the multislice computed coronary angiography (MSCT) must try to account by the clinician in order to ruling out coronary artery disease (CAD) in workers with LBBB and low cardiovascular risk.展开更多
Rationale:Acute myocardial infarction in the presence of right bundle branch block.Patient concerns:A 70-year-old,male heavy smoker presented with angina and hypertension.Interventions:Electrocardiography,intravenous ...Rationale:Acute myocardial infarction in the presence of right bundle branch block.Patient concerns:A 70-year-old,male heavy smoker presented with angina and hypertension.Interventions:Electrocardiography,intravenous nitroglycerin infusion,intravenous streptokinase infusion.Diagnosis:Acute myocardial infarction in the presence of with changeable trifascicular heart block.Outcomes:Dramatic clinical improvement with electrocardiographic ST-segment (whether elevation or reciprocal ST-depression) resolution.Lessons:Acute myocardial infarction may be associated right bundle branch block.Accompanied trifascicular heart block had pre-streptokinase left anterior fascicular block with left axis deviation and post-streptokinase left posterior fascicular block with right axis deviation.展开更多
Objective: The purpose of this study was to evaluate cardiac features associated with newly detected left bundle branch block (LBBB) in the outpatient department. Methods: A total of 57 patients with LBBB pattern were...Objective: The purpose of this study was to evaluate cardiac features associated with newly detected left bundle branch block (LBBB) in the outpatient department. Methods: A total of 57 patients with LBBB pattern were evaluated using electrocardiography (ECG). Patients were assessed based on their sex, age, detailed history, and cardiovascular symptoms. Cardiac investigations including ECG and echocardiography were performed. Results:The study included 30 (52.6%) males and 27 (47.5%) females, aged between 35 and 80 years. Dyspnoea (35.1%) and chest pain (22.8%) were the most common symptoms. 54.4% were hypertensive and 17.5% were diabetics. 28% had Left ventricular systolic dysfunction, and 24.5% had aortic valve disease. Left ventricular hypertrophy without any other structural heart disease was present in 28% of the patients. Only 24.5% patients presented with LBBB had a structurally normal heart in echocardiography. Myocardial performance index in echocardiography was abnormal in LBBB irrespective of the presence of structural heart disease. Conclusion: The prevalence of LBBB was found to increase with age and had slight male preponderance. Dyspnoea on effort was the most common presenting complaint, followed by chest pain and incidental detection of ECG abnormality. Most of the patients were hypertensive. Only 24.5% patients with LBBB had a structurally normal heart. MPI was abnormally high in the presence of LBBB despite having a normal left ventricular ejection fraction.展开更多
The occurrence of left bundle branch block (LBBB) is quite common in clinical practice. The changes in cardiac repolarization, caused by this disorder of electric conduction, may mask the presence of an acute myocardi...The occurrence of left bundle branch block (LBBB) is quite common in clinical practice. The changes in cardiac repolarization, caused by this disorder of electric conduction, may mask the presence of an acute myocardial infarction (AMI), delaying the diagnostic-therapeutic iter, with an important impact on prognosis. We describe the case of a woman of 59 years with LBBB, came to our observation for a constrictive chest pain associated with dyspnea. The diagnostic workup for suspected acute coronary syndrome (ACS), initially conducted only on the analysis of the electrocardiogram (negative TnI at entry), showed the presence of coronary arteries free of stenosis. However, the diagnostic confirmation of AMI was completed after the rise of cardiac markers and the electrocardiographic changes. This case confirm the difficulty about the diagnosis of AMI in patients with LBBB and stresses, however, as the use of some criteria proposed in the literature [1-3] can guide to its identification, directing patient to an appropriate treatment.展开更多
The present study aims to determine the influence of microvascular dysfunction (MVD) in the prognosis of patients presenting isolated left bundle branch block (LBBB). Methods: We studied 30 patients (pts), 22 males, 8...The present study aims to determine the influence of microvascular dysfunction (MVD) in the prognosis of patients presenting isolated left bundle branch block (LBBB). Methods: We studied 30 patients (pts), 22 males, 8 females, mean age 57 ± 4 years, with isolated LBBB, with a mean follow up of 48 ± 6 months. The control group consisted of 20 healthy individuals, 12 males, mean age 52 ± 10 years. Both groups were screened for cardiovascular risk factors (RF);they also had an echocardiogram and Coronary CT Scan, ruling out both structural heart disease and obstructive lesions of the epicardial coronary arteries. A myocardial perfusion study was then performed, with two groups emerging according to these results: Group A, 8 pts (26%), with reversible perfusion defects, in which the diagnosis of MVD was suspected, and Group B, 22 pts (74%), with either normal perfusion or minor septal/apical reversible defects (related to LBBB). All Group A pts, and 9 of the Group B pts, underwent coronary arteriography, with intracoronary acetylcholine and nitroglycerine infusion, thus evaluating vasomotor response as endothelium dependent (acetylcholine) or endothelium independent (nitroglycerine). During follow up, we reviewed functional class, 12 lead ECG and echocardiogram on a yearly basis. Results: All Group A patients had an abnormal acetylcholine response;only three of them had abnormal response to nitroglycerine infusion, suggesting endothelium dependent MVD. Of those in Group B, only one patient had abnormal acetylcholine response. At the end of the follow up period, 3 pts (37%) in Group A, showed functional class decrease vs 5 pts (22%) of those in Group B. In Group A, a significant increase of End Diastolic Left Ventricle Diameter (EDLVD) was found (51.6 ± 3.6 vs 59.3 ± 6.8 mm;p < 0.05) with significant decrease in LVEF (62 ± 4.8 vs 46% ± 3.7%, p variation. In neither group major complications (death, heart failure admissions) were found. Conclusion: We confirm the association between MVD and a worse clinical prognosis in isolated LBBB patients. Repeated ischemia and myocardial fibrosis are highlighted as possible physiopathological mechanisms, precluding a progressive left ventricular function decrease, with a higher mortality and arrhythmia risk. Endothelial function preserving strategies, both preventive and therapeutic, might be useful in improving LBBB with MVD patient’s prognosis.展开更多
The aim of this retrospective practice audit was to assess the correlation between painful zygapophysial joints and changes seen in magnetic resonance imaging (MRI). Patients with unilateral pain were tested with cont...The aim of this retrospective practice audit was to assess the correlation between painful zygapophysial joints and changes seen in magnetic resonance imaging (MRI). Patients with unilateral pain were tested with controlled medial branch blocks. The MRI scans of patients with a positive response were compared blinded with normal MRI scans. The dimensions of the joint were assessed and osteoarthritis was graded. Fifteen symptomatic patients and 15 asymptomatic patients were included and evaluated. Comparison of the joints showed that the maximum diameter of symptomatic joints was significantly larger, and the grading of osteoarthritis was significantly higher for symptomatic joints. No healthy patient was assigned a grade 3. Grades 2 and 3 were found significantly more often in symptomatic patients. Only one symptomatic joint was assigned grade 0. Grade 0 was found significantly more often in asympto-matic patients. The presented MRI technique has limited value as a diagnostic test for lumbar zygapophysial joint pain. It is not possible to detect a single symptomatic joint. However, the osteoarthritis grading for the lumbar zyg-apophysial joints might be helpful for finding predictors for negative response if the results of the rating are grade zero. Therefore, unnecessary medial branch blocks might be avoided.展开更多
Purpose: Regadenoson (REG) is currently becoming the stress agent of choice in patients undergoing pharmacologic single photon emission computed tomography (SPECT). However, in patients with left bundle branch block (...Purpose: Regadenoson (REG) is currently becoming the stress agent of choice in patients undergoing pharmacologic single photon emission computed tomography (SPECT). However, in patients with left bundle branch block (LBBB) and ventricular paced rhythm (VPR), hesitation exists amongst clinicians to use REG-SPECT due to the concern that the increased heart rate could cause false positive SPECT results. We sought to evaluate the comparability of A-SPECT and REG-SPECT in patients with LBBB and VPR. Methods: Retrospective study of 30 patients who served as their own controls. All 30 patients who underwent REG-SPECT (Grp 1) were compared to their prior A-SPECT (Grp 2) done within two years prior to REG-SPECT. Heart rate (HR) and blood pressure (BP) parameters, ECG, stress perfusion and gated variables, SPECT ischemia, and side-effects were evaluated. Statistical significance was set at P < 0.05. Results: Grp 1 and Grp 2 were comparable in hemodynamic parameters with increase in HR and decrease in systolic and diastolic BP with administration of adenosine and REG stress agents. However, there were no significant differences found in hemodynamic parameters and II degree AV block between the groups. All normal A-SPECT were found to be normal with REG-SPECT. No differences could be found between the two groups among SPECT parameters. Muscle pain was significantly higher in REG (10.0% vs. 0.0%, P = 0.083) and so was the use of aminophylline (16.7% vs. 0.0%, P = 0.025) to relieve the side-effect. Conclusion: REG-SPECT can be administered in patients with LBBB and VPR patients based on favorable and comparable hemodynamic responses and arrhythmia occurrences to A-SPECT. REG-SPECT can also be used for adequate interpretation of presence or absence of SPECT ischemia particularly in the LAD territory without any concern for false positive perfusion defects.展开更多
This paper constructs a new kind of block based bivariate blending rational interpolation via symmetric branched continued fractions. The construction process may be outlined as follows. The first step is to divide th...This paper constructs a new kind of block based bivariate blending rational interpolation via symmetric branched continued fractions. The construction process may be outlined as follows. The first step is to divide the original set of support points into some subsets (blocks). Then construct each block by using symmetric branched continued fraction. Finally assemble these blocks by Newton’s method to shape the whole interpolation scheme. Our new method offers many flexible bivariate blending rational interpolation schemes which include the classical bivariate Newton’s polynomial interpolation and symmetric branched continued fraction interpolation as its special cases. The block based bivariate blending rational interpolation is in fact a kind of tradeoff between the purely linear interpolation and the purely nonlinear interpolation. Finally, numerical examples are given to show the effectiveness of the proposed method.展开更多
BACKGROUND Coronavirus disease 2019(COVID-19)caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)has resulted in a worldwide health crisis since it first appeared.Numerous studies demonstrated the...BACKGROUND Coronavirus disease 2019(COVID-19)caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)has resulted in a worldwide health crisis since it first appeared.Numerous studies demonstrated the virus’s predilection to cardiomyocytes;however,the effects that COVID-19 has on the cardiac conduc-tion system still need to be fully understood.AIM To analyze the impact that COVID-19 has on the odds of major cardiovascular complications in patients with new onset heart blocks or bundle branch blocks(BBB).METHODS The 2020 National Inpatient Sample(NIS)database was used to identify patients admitted for COVID-19 pneumonia with and without high-degree atrioven-tricular blocks(HDAVB)and right or left BBB utilizing ICD-10 codes.The patients with pre-existing pacemakers,suggestive of a prior diagnosis of HDAVB or BBB,were excluded from the study.The primary outcome was inpatient mortality.Secondary outcomes included total hospital charges(THC),the length of hospital stay(LOS),and other major cardiac outcomes detailed in the Results section.Univariate and multivariate regression analyses were used to adjust for confounders with Stata version 17.RESULTS A total of 1058815 COVID-19 hospitalizations were identified within the 2020 NIS database,of which 3210(0.4%)and 17365(1.6%)patients were newly diagnosed with HDAVB and BBB,respectively.We observed a significantly higher odds of in-hospital mortality,cardiac arrest,cardiogenic shock,sepsis,arrythmias,and acute kidney injury in the COVID-19 and HDAVB group.There was no statistically significant difference in the odds of cerebral infarction or pulmonary embolism.Encounters with COVID-19 pneumonia and newly diagnosed BBB had a higher odds of arrythmias,acute kidney injury,sepsis,need for mechanical ventilation,and cardiogenic shock than those without BBB.However,unlike HDAVB,COVID-19 pneumonia and BBB had no significant impact on mortality compared to patients without BBB.CONCLUSION In conclusion,there is a significantly higher odds of inpatient mortality,cardiac arrest,cardiogenic shock,sepsis,acute kidney injury,supraventricular tachycardia,ventricular tachycardia,THC,and LOS in patients with COVID-19 pneumonia and HDAVB as compared to patients without HDAVB.Likewise,patients with COVID-19 pneumonia in the BBB group similarly have a higher odds of supraventricular tachycardia,atrial fibrillation,atrial flutter,ventricular tachycardia,acute kidney injury,sepsis,need for mechanical ventilation,and cardiogenic shock as compared to those without BBB.Therefore,it is essential for healthcare providers to be aware of the possible worse predicted outcomes that patients with new-onset HDAVB or BBB may experience following SARS-CoV-2 infection.展开更多
目的探讨左束支区域起搏(left bundle branch area pacing,LBBaP)对房室传导阻滞(AVB)患者术后新发心房颤动(new-onset atrial fibrillation,NOAF)和心房高频事件(atrial high rate episodes,AHREs)的影响。方法回顾性纳入84例行起搏治...目的探讨左束支区域起搏(left bundle branch area pacing,LBBaP)对房室传导阻滞(AVB)患者术后新发心房颤动(new-onset atrial fibrillation,NOAF)和心房高频事件(atrial high rate episodes,AHREs)的影响。方法回顾性纳入84例行起搏治疗的三度房室传导阻滞(ⅢAVB)患者,根据心室电极位置分为LBBaP组(n=42)和右室间隔部起搏(RVSP)组(n=42)。比较两组患者术前术后QRS波时限(QRSd)、心室起搏参数,并发症、脑卒中事件和NOAF、AHREs发生率。结果(1)LBBaP组术后NOAF、AHREs发生率均低于RVSP组(P<0.05)。(2)LBBaP组的p-QRSd短于RVSP组(P<0.05)。(3)两组患者心室起搏参数、并发症及脑卒中事件发生率之间差异无统计学意义(P>0.05)。结论相对于右室起搏,LBBaP术后AHREs、NOAF的发生率较低,可改善患者预后。展开更多
直流系统是支撑高比例新能源接入与灵活高效用能的重要技术方向。固态式直流断路器(solid state DC circuit breaker,SSCB)具有开断速度极快、无电弧、寿命长等优点,在中低压直流系统的故障保护中得到广泛应用。随着电力电子器件的发展...直流系统是支撑高比例新能源接入与灵活高效用能的重要技术方向。固态式直流断路器(solid state DC circuit breaker,SSCB)具有开断速度极快、无电弧、寿命长等优点,在中低压直流系统的故障保护中得到广泛应用。随着电力电子器件的发展,固态式直流断路器的拓扑结构、工作性能也在不断进步。为此基于逆阻型集成门极换流晶闸管(intergated gate commutate thyristor,IGCT),提出了一种新型的固态式直流断路器结构及设计方法,通流支路采用逆阻IGCT反并联结构实现双向通流,缓冲支路采用金属氧化物避雷器(metal oxide varistor,MOV)-电容结构来抑制过电压,吸能支路采用MOV吸收系统能量。进一步地,给出了关键元器件的参数设计方法,并验证了有效性;设计了性能良好的重力热管散热器,单个模块散热功率可达700 W;提出了主被动结合的控保策略,提高断路器的保护性能。最后,研制了固态式直流断路器样机,可用于750 V以内的低压直流系统,额定通流可达2 kA,可在百微秒内开断10 kA故障电流,成本低、体积小、高可靠,具有良好的应用前景。展开更多
文摘The deleterious effects of long-term right ventricular pacing necessitated the search for alternative pacing sites which could prevent or alleviate pacinginduced cardiomyopathy.Until recently,biventricular pacing(BiVP)was the only modality which could mitigate or prevent pacing induced dysfunction.Further,BiVP could resynchronize the baseline electromechanical dssynchrony in heart failure and improve outcomes.However,the high non-response rate of around 20%-30%remains a major limitation.This non-response has been largely attributable to the direct non-physiological stimulation of the left ventricular myocardium bypassing the conduction system.To overcome this limitation,the concept of conduction system pacing(CSP)came up.Despite initial success of the first CSP via His bundle pacing(HBP),certain drawbacks including lead instability and dislodgements,steep learning curve and rapid battery depletion on many occasions prevented its widespread use for cardiac resynchronization therapy(CRT).Subsequently,CSP via left bundle branch-area pacing(LBBP)was developed in 2018,which over the last few years has shown efficacy comparable to BiVP-CRT in small observational studies.Further,its safety has also been well established and is largely free of the pitfalls of the HBP-CRT.In the recent metanalysis by Yasmin et al,comprising of 6 studies with 389 participants,LBBPCRT was superior to BiVP-CRT in terms of QRS duration,left ventricular ejection fraction,cardiac chamber dimensions,lead thresholds,and functional status amongst heart failure patients with left bundle branch block.However,there are important limitations of the study including the small overall numbers,inclusion of only a single small randomized controlled trial(RCT)and a small follow-up duration.Further,the entire study population analyzed was from China which makes generalizability a concern.Despite the concerns,the meta-analysis adds to the growing body of evidence demonstrating the efficacy of LBBP-CRT.At this stage,one must acknowledge that the fact that still our opinions on this technique are largely based on observational data and there is a dire need for larger RCTs to ascertain the position of LBBPCRT in management of heart failure patients with left bundle branch block.
文摘Exercise-induced left bundle branch block(EI-LBBB)is infrequent phenomenon.We present two patients with angina pectoris who developed EI-LBBB during exercise tolerance test.The first patient with typical angina pectoris had significant obstructive coronary artery disease(CAD)requiring percutaneous coronary intervention of multiple lesions including placement of drug eluting stents.The second patient had atypical chest pain without signs of CAD at all.EI-LBBB occurred at a heart rate of 80 bpm and 141 bpm in the first and second patient,respectively.EI-LBBB remained visible through the test till the recovery period in the first patient at a heart rate of 83 bpm and disappeared at 96bpm in the second patient.Both patients with this infrequent phenomenon are discussed and the literature is reviewed.
文摘The evaluation of wide QRS complex tachycardias (WCT)remains a common dilemma for clinicians.Numerous algorithms exist to aid in arriving at the correct diagnosis.Unfortunately,these algorithms are difficult to remember,and overreliance on them may prevent cardiologists from understanding the mechanisms underlying these arrhythmias.One distinct subcategory of WCTs are those that present with a"typical"or"classic" left bundle branch block pattern.These tachycardias may be supraventricular or ventricular in origin and arise from functional or fixed aberrancy,bystander or participating atriofascicular pre-excitation,and bundle branch reentry.This review will describe these arrhythmias,illustrate their mechanisms,and discuss their clinical features and treatment strategies.
文摘A 54-year-old female patient with congenital heart disease had a persistent complete left bundle branch block three months after closure by an Amplatzer ventricular septal defect occluder. Nine months later, the patient suffered from chest distress, palpitation, and sweating at daily activities, and her 6-min walk distance decreased significantly (155 m). Her echocardiography showed increased left ventricular end-diastolic diameter with left ventricular ejection fraction of 37%. Her symptoms reduced significantly one week after received cardiac resynchronization therapy. She had no symptoms at daily activities, and her echo showed left ventricular ejection fraction of 46%and 53%. Moreover, left ventricular end-diastolic diameter decreased 6 and 10 months after cardiac resynchronization therapy, and 6-min walk dis-tance remarkably increased. This case demonstrated that persistent complete left bundle branch block for nine months after transcatheter closure with ventricular septal defect Amplatzer occluder could lead to left ventricular enlargement and a significant decrease in left ventricular systolic function. Cardiac resynchronization therapy decreased left ventricular end-diastolic diameter and increased left ventricular ejection fraction, thereby improving the patient’s heart functions.
文摘Left bundle branch block(LBBB)causes a delay in left ventricular contraction with an unsynchronized ventricular systole.LBBB is an independent determinant of morbi-mortality mainly when associated with cardiomyopathy and left ventricular dysfunction.[1] LBBB due to non-ischemic cardiomyopathy is considered non-reversible.Such irreversibility occurs because LBBB and cardiomyopathy act in a synergic manner in order to maintain both situations.However,there are a few reports in the literature showing that some patients have had an improvement in cardiac function with normalization of QRS and have experienced a reverse remodelling with pharmacological therapy only.[2–4]
文摘Aims: Left bundle branch block (LBBB) is generally associated with a poorer prognosis in comparison to normal intraventricular conduction, but also in comparison to right bundle branch block which is generally considered to be benign in the absence of an underlying cardiac disorder like congenital heart disease. In this paper we evaluate the presence of possible cardiovascular pathology in a group of nurses with a low level of cardiovascular risk factors and left bundle branch block (LBBB). Methods: During the period 2009-2013, 356 nurses (mean age: 32.6 ± 11 yr) were admitted to the department of Occupational Medicine of Second University of Naples. Of these, 13 had LBBB. The evaluation of these patients has included an electrocardiogram (ECG), echocardiography, 24-h ambulatory Holter monitoring (ECG Holter), and exercise testing. Subsequently, in patients with LBBB, multislice computed coronary angiography (MSCT) has been considered. Results and Conclusion: Only in one patient we found a significant stenosis in the middle tract of left anterior descending artery. Coronary artery disease remains difficult to diagnose in some ECG findings such as acquired LBBB. For this reason, a preventive diagnose with newly developed diagnostic methods such as the multislice computed coronary angiography (MSCT) must try to account by the clinician in order to ruling out coronary artery disease (CAD) in workers with LBBB and low cardiovascular risk.
文摘Rationale:Acute myocardial infarction in the presence of right bundle branch block.Patient concerns:A 70-year-old,male heavy smoker presented with angina and hypertension.Interventions:Electrocardiography,intravenous nitroglycerin infusion,intravenous streptokinase infusion.Diagnosis:Acute myocardial infarction in the presence of with changeable trifascicular heart block.Outcomes:Dramatic clinical improvement with electrocardiographic ST-segment (whether elevation or reciprocal ST-depression) resolution.Lessons:Acute myocardial infarction may be associated right bundle branch block.Accompanied trifascicular heart block had pre-streptokinase left anterior fascicular block with left axis deviation and post-streptokinase left posterior fascicular block with right axis deviation.
文摘Objective: The purpose of this study was to evaluate cardiac features associated with newly detected left bundle branch block (LBBB) in the outpatient department. Methods: A total of 57 patients with LBBB pattern were evaluated using electrocardiography (ECG). Patients were assessed based on their sex, age, detailed history, and cardiovascular symptoms. Cardiac investigations including ECG and echocardiography were performed. Results:The study included 30 (52.6%) males and 27 (47.5%) females, aged between 35 and 80 years. Dyspnoea (35.1%) and chest pain (22.8%) were the most common symptoms. 54.4% were hypertensive and 17.5% were diabetics. 28% had Left ventricular systolic dysfunction, and 24.5% had aortic valve disease. Left ventricular hypertrophy without any other structural heart disease was present in 28% of the patients. Only 24.5% patients presented with LBBB had a structurally normal heart in echocardiography. Myocardial performance index in echocardiography was abnormal in LBBB irrespective of the presence of structural heart disease. Conclusion: The prevalence of LBBB was found to increase with age and had slight male preponderance. Dyspnoea on effort was the most common presenting complaint, followed by chest pain and incidental detection of ECG abnormality. Most of the patients were hypertensive. Only 24.5% patients with LBBB had a structurally normal heart. MPI was abnormally high in the presence of LBBB despite having a normal left ventricular ejection fraction.
文摘The occurrence of left bundle branch block (LBBB) is quite common in clinical practice. The changes in cardiac repolarization, caused by this disorder of electric conduction, may mask the presence of an acute myocardial infarction (AMI), delaying the diagnostic-therapeutic iter, with an important impact on prognosis. We describe the case of a woman of 59 years with LBBB, came to our observation for a constrictive chest pain associated with dyspnea. The diagnostic workup for suspected acute coronary syndrome (ACS), initially conducted only on the analysis of the electrocardiogram (negative TnI at entry), showed the presence of coronary arteries free of stenosis. However, the diagnostic confirmation of AMI was completed after the rise of cardiac markers and the electrocardiographic changes. This case confirm the difficulty about the diagnosis of AMI in patients with LBBB and stresses, however, as the use of some criteria proposed in the literature [1-3] can guide to its identification, directing patient to an appropriate treatment.
文摘The present study aims to determine the influence of microvascular dysfunction (MVD) in the prognosis of patients presenting isolated left bundle branch block (LBBB). Methods: We studied 30 patients (pts), 22 males, 8 females, mean age 57 ± 4 years, with isolated LBBB, with a mean follow up of 48 ± 6 months. The control group consisted of 20 healthy individuals, 12 males, mean age 52 ± 10 years. Both groups were screened for cardiovascular risk factors (RF);they also had an echocardiogram and Coronary CT Scan, ruling out both structural heart disease and obstructive lesions of the epicardial coronary arteries. A myocardial perfusion study was then performed, with two groups emerging according to these results: Group A, 8 pts (26%), with reversible perfusion defects, in which the diagnosis of MVD was suspected, and Group B, 22 pts (74%), with either normal perfusion or minor septal/apical reversible defects (related to LBBB). All Group A pts, and 9 of the Group B pts, underwent coronary arteriography, with intracoronary acetylcholine and nitroglycerine infusion, thus evaluating vasomotor response as endothelium dependent (acetylcholine) or endothelium independent (nitroglycerine). During follow up, we reviewed functional class, 12 lead ECG and echocardiogram on a yearly basis. Results: All Group A patients had an abnormal acetylcholine response;only three of them had abnormal response to nitroglycerine infusion, suggesting endothelium dependent MVD. Of those in Group B, only one patient had abnormal acetylcholine response. At the end of the follow up period, 3 pts (37%) in Group A, showed functional class decrease vs 5 pts (22%) of those in Group B. In Group A, a significant increase of End Diastolic Left Ventricle Diameter (EDLVD) was found (51.6 ± 3.6 vs 59.3 ± 6.8 mm;p < 0.05) with significant decrease in LVEF (62 ± 4.8 vs 46% ± 3.7%, p variation. In neither group major complications (death, heart failure admissions) were found. Conclusion: We confirm the association between MVD and a worse clinical prognosis in isolated LBBB patients. Repeated ischemia and myocardial fibrosis are highlighted as possible physiopathological mechanisms, precluding a progressive left ventricular function decrease, with a higher mortality and arrhythmia risk. Endothelial function preserving strategies, both preventive and therapeutic, might be useful in improving LBBB with MVD patient’s prognosis.
文摘The aim of this retrospective practice audit was to assess the correlation between painful zygapophysial joints and changes seen in magnetic resonance imaging (MRI). Patients with unilateral pain were tested with controlled medial branch blocks. The MRI scans of patients with a positive response were compared blinded with normal MRI scans. The dimensions of the joint were assessed and osteoarthritis was graded. Fifteen symptomatic patients and 15 asymptomatic patients were included and evaluated. Comparison of the joints showed that the maximum diameter of symptomatic joints was significantly larger, and the grading of osteoarthritis was significantly higher for symptomatic joints. No healthy patient was assigned a grade 3. Grades 2 and 3 were found significantly more often in symptomatic patients. Only one symptomatic joint was assigned grade 0. Grade 0 was found significantly more often in asympto-matic patients. The presented MRI technique has limited value as a diagnostic test for lumbar zygapophysial joint pain. It is not possible to detect a single symptomatic joint. However, the osteoarthritis grading for the lumbar zyg-apophysial joints might be helpful for finding predictors for negative response if the results of the rating are grade zero. Therefore, unnecessary medial branch blocks might be avoided.
文摘Purpose: Regadenoson (REG) is currently becoming the stress agent of choice in patients undergoing pharmacologic single photon emission computed tomography (SPECT). However, in patients with left bundle branch block (LBBB) and ventricular paced rhythm (VPR), hesitation exists amongst clinicians to use REG-SPECT due to the concern that the increased heart rate could cause false positive SPECT results. We sought to evaluate the comparability of A-SPECT and REG-SPECT in patients with LBBB and VPR. Methods: Retrospective study of 30 patients who served as their own controls. All 30 patients who underwent REG-SPECT (Grp 1) were compared to their prior A-SPECT (Grp 2) done within two years prior to REG-SPECT. Heart rate (HR) and blood pressure (BP) parameters, ECG, stress perfusion and gated variables, SPECT ischemia, and side-effects were evaluated. Statistical significance was set at P < 0.05. Results: Grp 1 and Grp 2 were comparable in hemodynamic parameters with increase in HR and decrease in systolic and diastolic BP with administration of adenosine and REG stress agents. However, there were no significant differences found in hemodynamic parameters and II degree AV block between the groups. All normal A-SPECT were found to be normal with REG-SPECT. No differences could be found between the two groups among SPECT parameters. Muscle pain was significantly higher in REG (10.0% vs. 0.0%, P = 0.083) and so was the use of aminophylline (16.7% vs. 0.0%, P = 0.025) to relieve the side-effect. Conclusion: REG-SPECT can be administered in patients with LBBB and VPR patients based on favorable and comparable hemodynamic responses and arrhythmia occurrences to A-SPECT. REG-SPECT can also be used for adequate interpretation of presence or absence of SPECT ischemia particularly in the LAD territory without any concern for false positive perfusion defects.
基金Project supported by the National Natural Science Foundation of China (No. 10171026, No. 60473114) the AnhuiProvincial Natural Science Foundation, China (No. 03046102)the Research Funds for Young InnovationGroup, Education Department of Anhui Province (No. 2005TD03).
文摘This paper constructs a new kind of block based bivariate blending rational interpolation via symmetric branched continued fractions. The construction process may be outlined as follows. The first step is to divide the original set of support points into some subsets (blocks). Then construct each block by using symmetric branched continued fraction. Finally assemble these blocks by Newton’s method to shape the whole interpolation scheme. Our new method offers many flexible bivariate blending rational interpolation schemes which include the classical bivariate Newton’s polynomial interpolation and symmetric branched continued fraction interpolation as its special cases. The block based bivariate blending rational interpolation is in fact a kind of tradeoff between the purely linear interpolation and the purely nonlinear interpolation. Finally, numerical examples are given to show the effectiveness of the proposed method.
文摘BACKGROUND Coronavirus disease 2019(COVID-19)caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)has resulted in a worldwide health crisis since it first appeared.Numerous studies demonstrated the virus’s predilection to cardiomyocytes;however,the effects that COVID-19 has on the cardiac conduc-tion system still need to be fully understood.AIM To analyze the impact that COVID-19 has on the odds of major cardiovascular complications in patients with new onset heart blocks or bundle branch blocks(BBB).METHODS The 2020 National Inpatient Sample(NIS)database was used to identify patients admitted for COVID-19 pneumonia with and without high-degree atrioven-tricular blocks(HDAVB)and right or left BBB utilizing ICD-10 codes.The patients with pre-existing pacemakers,suggestive of a prior diagnosis of HDAVB or BBB,were excluded from the study.The primary outcome was inpatient mortality.Secondary outcomes included total hospital charges(THC),the length of hospital stay(LOS),and other major cardiac outcomes detailed in the Results section.Univariate and multivariate regression analyses were used to adjust for confounders with Stata version 17.RESULTS A total of 1058815 COVID-19 hospitalizations were identified within the 2020 NIS database,of which 3210(0.4%)and 17365(1.6%)patients were newly diagnosed with HDAVB and BBB,respectively.We observed a significantly higher odds of in-hospital mortality,cardiac arrest,cardiogenic shock,sepsis,arrythmias,and acute kidney injury in the COVID-19 and HDAVB group.There was no statistically significant difference in the odds of cerebral infarction or pulmonary embolism.Encounters with COVID-19 pneumonia and newly diagnosed BBB had a higher odds of arrythmias,acute kidney injury,sepsis,need for mechanical ventilation,and cardiogenic shock than those without BBB.However,unlike HDAVB,COVID-19 pneumonia and BBB had no significant impact on mortality compared to patients without BBB.CONCLUSION In conclusion,there is a significantly higher odds of inpatient mortality,cardiac arrest,cardiogenic shock,sepsis,acute kidney injury,supraventricular tachycardia,ventricular tachycardia,THC,and LOS in patients with COVID-19 pneumonia and HDAVB as compared to patients without HDAVB.Likewise,patients with COVID-19 pneumonia in the BBB group similarly have a higher odds of supraventricular tachycardia,atrial fibrillation,atrial flutter,ventricular tachycardia,acute kidney injury,sepsis,need for mechanical ventilation,and cardiogenic shock as compared to those without BBB.Therefore,it is essential for healthcare providers to be aware of the possible worse predicted outcomes that patients with new-onset HDAVB or BBB may experience following SARS-CoV-2 infection.
文摘目的探讨左束支区域起搏(left bundle branch area pacing,LBBaP)对房室传导阻滞(AVB)患者术后新发心房颤动(new-onset atrial fibrillation,NOAF)和心房高频事件(atrial high rate episodes,AHREs)的影响。方法回顾性纳入84例行起搏治疗的三度房室传导阻滞(ⅢAVB)患者,根据心室电极位置分为LBBaP组(n=42)和右室间隔部起搏(RVSP)组(n=42)。比较两组患者术前术后QRS波时限(QRSd)、心室起搏参数,并发症、脑卒中事件和NOAF、AHREs发生率。结果(1)LBBaP组术后NOAF、AHREs发生率均低于RVSP组(P<0.05)。(2)LBBaP组的p-QRSd短于RVSP组(P<0.05)。(3)两组患者心室起搏参数、并发症及脑卒中事件发生率之间差异无统计学意义(P>0.05)。结论相对于右室起搏,LBBaP术后AHREs、NOAF的发生率较低,可改善患者预后。