Patients with left bundle branch block and left axis deviation show a specific left ventricular asynchrony pattern: Implications for left ventricular lead placement during CRT implantation

Sciarra, Luigi; Golia, Paolo; Palamà, Zefferino; Scarà, Antonio; Ruvo, Ermenegildo De; Borrelli, Alessio; Martino, Anna Maria; Minati, Monia; Fagagnini, Alessandro; Tota, Claudia; Luca, Lucia De; Grieco, Domenico; Delise, P; Calò, Leonardo

doi:10.1016/j.jelectrocard.2017.10.006

Cited by 8 publications

(8 citation statements)

References 24 publications

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“…The small number of patients in our study precludes any strong conclusions since ECG pattern of left axis deviation may be caused by different factors similarly as LBBB pattern. However, we have not confirmed findings of Sciarra et al 12 . The two patients with left axis deviation in our study exhibited latest activation site laterally, similarly as the others.…”

Section: Discussioncontrasting

confidence: 99%

“…It is believed that it marks more advanced conduction disturbance and structural abnormality and thus worse prognosis 11 . Sciarra et al 12 reported that the latest LV segment in LBBB with left axis deviation is located anteriorly compared to the lateral wall in LBBB with the normal axis. The small number of patients in our study precludes any strong conclusions since ECG pattern of left axis deviation may be caused by different factors similarly as LBBB pattern.…”

Section: Discussionmentioning

confidence: 99%

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Is left bundle branch block pattern on the ECG caused by variable ventricular activation sequence?

Riedlbauchová

Adla

Suchánek

et al. 2020

Pacing Clinical Electrophis

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Background:The presence and extent of ventricular dyssynchrony are currently assessed from the QRS complex morphology and width. However, similar electrocardiography (ECG) pattern may be caused by variable ventricular activation sequence. This may then contribute to interindividually different response to cardiac resynchronization therapy (CRT).Methods: Electroanatomical mapping and magnetic resonance imaging scan were performed in 11 patients with left bundle branch block (LBBB, QRS 170 ± 14 ms) and heart failure of ischemic (coronary artery disease (CAD), n = 2) and nonischemic (dilated cardiomyopathy (DCM), n = 9) etiology. Ventricular activation sequence was studied during LBBB and final CRT programming.Presence and extent of scarring were analyzed in the 17-segment left-ventricular (LV) model. Results: Regardless of etiology, presence of typical LBBB was associated with diffuse prolongation of impulse conduction with right-to-left activation sequence. Basal lateral wall was constant site of late activation. This activation pattern was present in "true LBBB," but also in LBBB-like pattern (persistent S wave in V5-6) and left axis deviation. Activation started in right vetricular (RV) apex in patients with left axis deviation at RV free wall in normal axis. Individuals with CAD and DCM patient displayed focal scar. Despite that they exhibited typical LBBB and activation sequence mirrored findings in other LBBB individuals. Reverse remodeling (∆LVESV > 15% after 6 months) was evident in 10 patients. Conclusions: Both typical LBBB and LBBB-like pattern might be associated with constant activation sequence regardless of etiology and scar localization. Activation initiation in RV apex, not LV activation sequence can be surrogate for left axis deviation. CRT caused inter-and intraventricular LV resynchronization without significantly changed RV activation sequence and duration.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Is left bundle branch block pattern on the ECG caused by variable ventricular activation sequence?

Riedlbauchová

Adla

Suchánek

et al. 2020

Pacing Clinical Electrophis

View full text Add to dashboard Cite

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“…Given that the LV lead position was recommended in the posterolateral to lateral site in a large-scale randomized clinical trial that proved CRT efficacy (1,2), many cardiologists generally place the LV lead at the LV posterolateral site. However, the appropriate LV lead position to restore electrical synchrony depends on the underlying conduction disturbances (3).A recent study showed that in patients with left bundle branch block (LBBB) and left axis deviation, the latest activation site was not the LV posterolateral site but the anterolateral site (11). Therefore, the CRT response was weaker in patients with LBBB and left-axis deviation than in patients with LBBB without left-axis deviation (12,13).…”

Section: Discussionmentioning

confidence: 99%

Preferred left ventricular lead position for upgrade from right ventricular pacing to cardiac resynchronization therapy

Ogano

Iwasaki

Okada

et al. 2023

Preprint

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Background: Cardiac resynchronization therapy (CRT) is a well-established treatment for symptomatic heart failure with electrical dyssynchrony. The left ventricle (LV) lead position is recommended at LV posterolateral to lateral sites in patients with left bundle branch block; however, its preferred region remains unclear in patients upgrading from conventional right ventricular (RV) apical pacing to CRT. We aimed to identify the preferred LV lead position for upgrading conventional RV apical pacing to CRT. Methods: This study used electrode catheters positioned at the RV apex and LV anterolateral and posterolateral sites via the coronary sinus (CS) branches to measure the ratio of activation time to QRS duration from the RV apex to the LV anterolateral and LV posterolateral sites during RV apical pacing. We performed simultaneous biventricular pacing at the RV apex and each LV site and measured the differences in QRS duration and LV dP/dtmax from those of RV apical pacing. Results: This study included 37 patients with anterolateral and posterolateral LV CS branches. During RV apical pacing, the average ratio of activation time to QRS duration was higher at the LV anterolateral site than at the LV posterolateral site (0.90±0.06 vs. 0.71±0.11, p<0.001). The decreasing ratio of QRS duration and the increasing ratio of LV dP/dtmax were higher at the LV anterolateral site than at the LV posterolateral site (45.7±18.0% vs. 32.0±17.6%, p<0.001 and 12.7±2.9% vs. 3.7±8.2%, p<0.001, respectively) during biventricular pacing compared with those during RV apical pacing. Conclusions: The LV lead position is preferred at the LV anterolateral site in patients upgrading from conventional RV apical pacing to CRT.

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“…However, according to the results of the systematic review, their benefit needs to be verified by randomized controlled studies [ 82 ]. Considering the persisting number of patients not benefiting from CMR, the location of the lead positions remains challenging with respect to the specific left ventricular asynchrony patterns [ 83 ].…”

Section: Discussionmentioning

confidence: 99%

The Primary Alteration of Ventricular Myocardium Conduction: The Significant Determinant of Left Bundle Branch Block Pattern

Bachárová

Bayés-de-Luna

2022

Cardiology Research and Practice

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Intraventricular conduction disturbances (IVCD) are currently generally accepted as ECG diagnostic categories. They are characterized by defined QRS complex patterns that reflect the abnormalities in the intraventricular sequence of activation that can be caused by pathology in the His-Purkinje conduction system (HP) or ventricular myocardium. However, the current understanding of the IVCD’s underlying mechanism is mostly attributed to HP structural or functional alterations. The involvement of the working ventricular myocardium is only marginally mentioned or not considered. This opinion paper is focused on the alterations of the ventricular working myocardium leading to the most frequent IVCD pattern—the left bundle branch block pattern (LBBB). Recognizing the underlying mechanisms of the LBBB patterns and the involvement of the ventricular working myocardium is of utmost clinical importance, considering a patient’s prognosis and indication for cardiac resynchronization therapy.

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Patients with left bundle branch block and left axis deviation show a specific left ventricular asynchrony pattern: Implications for left ventricular lead placement during CRT implantation

Cited by 8 publications

References 24 publications

Is left bundle branch block pattern on the ECG caused by variable ventricular activation sequence?

Is left bundle branch block pattern on the ECG caused by variable ventricular activation sequence?

Preferred left ventricular lead position for upgrade from right ventricular pacing to cardiac resynchronization therapy

The Primary Alteration of Ventricular Myocardium Conduction: The Significant Determinant of Left Bundle Branch Block Pattern

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