Bifascicular block

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Bifascicular block
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Bifascicular block is a conduction abnormality in the heart where two of the three main fascicles of the His-Purkinje system are blocked. Most commonly, it refers to a combination of right bundle branch block (RBBB) and either left anterior fascicular block (LAFB) or left posterior fascicular block (LPFB). Some authors consider left bundle branch block (LBBB) to be a technical bifascicular block, since the block occurs above the bifurcation of the left anterior and left posterior fascicles of the left bundle branch.

Diagnosis

Electrocardiogram

Bifascicular1.jpg

2008 ACC/AHA/HRS Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities (DO NOT EDIT)[1]

Permanent Pacing in Chronic Bifascicular Block (DO NOT EDIT)[1]

Class I
"1. Permanent pacemaker implantation is indicated for advanced second-degree AV block or intermittent third-degree AV block. (Level of Evidence: B)[2][3][4][5][6][7][8]"
"2. Permanent pacemaker implantation is indicated for type II second-degree AV block. (Level of Evidence: B)[9][10][11][12]"
"3. Permanent pacemaker implantation is indicated for alternating bundle-branch block. (Level of Evidence: C)"
Class III (No Benefit)
"1. Permanent pacemaker implantation is not indicated for fascicular block without AV block or symptoms. (Level of Evidence: B)[13][14][15][16]"
"2. Permanent pacemaker implantation is not indicated for fascicular block with first-degree AV block without symptoms. (Level of Evidence: B)[13][14][15][16]"
Class IIa
"1. Permanent pacemaker implantation is reasonable for syncope not demonstrated to be due to AV block when other likely causes have been excluded, specifically ventricular tachycardia (VT). (Level of Evidence: B)[12][17][18][13][19][14][20][21][15][16][22][23][24][25][26][27][28][29][30]"
"2. Permanent pacemaker implantation is reasonable for an incidental finding at electrophysiological study of a markedly prolonged HV interval (greater than or equal to 100 milliseconds) in asymptomatic patients. (Level of Evidence: B)[16]"
"3. Permanent pacemaker implantation is reasonable for an incidental finding at electrophysiological study of pacing-induced infra-His block that is not physiological. (Level of Evidence: B)[28]"
Class IIb
"1. Permanent pacemaker implantation may be considered in the setting of neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with bifascicular block or any fascicular block, with or without symptoms. (Level of Evidence: C)[31][32][33][34][35][36][37]"

Sources

  • The ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities [1]

References

  1. ↑ 1.0 1.1 1.2 Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207
  2. ↑ FRIEDBERG CK, DONOSO E, STEIN WG (1964). "NONSURGICAL ACQUIRED HEART BLOCK.". Ann N Y Acad Sci 111: 835-47. PMID 14206803.
  3. ↑ (1991) "Recommendations for pacemaker prescription for symptomatic bradycardia. Report of a working party of the British Pacing and Electrophysiology Group.". Br Heart J 66 (2): 185-91. PMID 1883673.
  4. ↑ GADBOYS HL, WISOFF G, LITWAK RS (1964). "SURGICAL TREATMENT OF COMPLETE HEART BLOCK. AN ANALYSIS OF 36 CASES.". JAMA 189: 97-102. PMID 14149997.
  5. ↑ Johansson BW (1966). "Complete heart block. A clinical, hemodynamic and pharmacological study in patients with and without an artificial pacemaker.". Acta Med Scand Suppl 451: 1-127. PMID 5223645.
  6. ↑ Hindman MC, Wagner GS, JaRo M, Atkins JM, Scheinman MM, DeSanctis RW et al. (1978). "The clinical significance of bundle branch block complicating acute myocardial infarction. 2. Indications for temporary and permanent pacemaker insertion.". Circulation 58 (4): 689-99. PMID 688580.
  7. ↑ Donmoyer TL, DeSanctis RW, Austen WG (1967). "Experience with implantable pacemakers using myocardial electrodes in the management of heart block.". Ann Thorac Surg 3 (3): 218-27. PMID 4951735.
  8. ↑ LEVINE SA, MILLER H, PENTON GB (1956). "Some clinical features of complete heart block.". Circulation 13 (6): 801-24. PMID 13356435.
  9. ↑ Dhingra RC, Denes P, Wu D, Chuquimia R, Rosen KM (1974). "The significance of second degree atrioventricular block and bundle branch block. Observations regarding site and type of block.". Circulation 49 (4): 638-46. PMID 4817704.
  10. ↑ DONOSO E, ADLER LN, FRIEDBERG CK (1964). "UNUSUAL FORMS OF SECOND-DEGREE ATRIOVENTRICULAR BLOCK, INCLUDING MOBITZ TYPE-II BLOCK, ASSOCIATED WITH THE MORGAGNI-ADAMS-STOKES SYNDROME.". Am Heart J 67: 150-7. PMID 14118480.
  11. ↑ Ranganathan N, Dhurandhar R, Phillips JH, Wigle ED (1972). "His Bundle electrogram in bundle-branch block.". Circulation 45 (2): 282-94. PMID 5009474.
  12. ↑ 12.0 12.1 Dhingra RC, Denes P, Wu D, Chuquimia R, Amat-y-Leon F, Wyndham C et al. (1974). "Syncope in patients with chronic bifascicular block. Significance, causative mechanisms, and clinical implications.". Ann Intern Med 81 (3): 302-6. PMID 4854561.
  13. ↑ 13.0 13.1 13.2 Scheinman MM, Peters RW, Modin G, Brennan M, Mies C, O'Young J (1977). "Prognostic value of infranodal conduction time in patients with chronic bundle branch block.". Circulation 56 (2): 240-4. PMID 872316.
  14. ↑ 14.0 14.1 14.2 McAnulty JH, Kauffman S, Murphy E, Kassebaum DG, Rahimtoola SH (1978). "Survival in patients with intraventricular conduction defects.". Arch Intern Med 138 (1): 30-5. PMID 619828.
  15. ↑ 15.0 15.1 15.2 McAnulty JH, Rahimtoola SH, Murphy E, DeMots H, Ritzmann L, Kanarek PE et al. (1982). "Natural history of "high-risk" bundle-branch block: final report of a prospective study.". N Engl J Med 307 (3): 137-43. doi:10.1056/NEJM198207153070301. PMID 7088050.
  16. ↑ 16.0 16.1 16.2 16.3 Scheinman MM, Peters RW, Suavé MJ, Desai J, Abbott JA, Cogan J et al. (1982). "Value of the H-Q interval in patients with bundle branch block and the role of prophylactic permanent pacing.". Am J Cardiol 50 (6): 1316-22. PMID 7148708.
  17. ↑ Kulbertus H, Collignon P (1969). "Association of right bundle-branch block with left superior or inferior intraventricular block. Its relation to complete heart block and Adams-Stokes syndrome.". Br Heart J 31 (4): 435-40. PMID 5791121.
  18. ↑ DePasquale NP, Bruno MS (1973). "Natural history of combined right bundle branch block and left anterior hemiblock (bilateral bundle branch block).". Am J Med 54 (3): 297-303. PMID 4689232.
  19. ↑ Denes P, Dhingra RC, Wu D, Wyndham CR, Amat-y-Leon F, Rosen KM (1977). "Sudden death in patients with chronic bifascicular block.". Arch Intern Med 137 (8): 1005-10. PMID 879938.
  20. ↑ Peters RW, Scheinman MM, Modin C, O'Young J, Somelofski CA, Mies C (1979). "Prophylactic permanent pacemakers for patients with chronic bundle branch block.". Am J Med 66 (6): 978-85. PMID 453228.
  21. ↑ Fisch GR, Zipes DP, Fisch C (1980). "Bundle branch block and sudden death.". Prog Cardiovasc Dis 23 (3): 187-224. PMID 7001541.
  22. ↑ Morady F, Higgins J, Peters RW, Schwartz AB, Shen EN, Bhandari A et al. (1984). "Electrophysiologic testing in bundle branch block and unexplained syncope.". Am J Cardiol 54 (6): 587-91. PMID 6475778.
  23. ↑ Click RL, Gersh BJ, Sugrue DD, Holmes DR, Wood DL, Osborn MJ et al. (1987). "Role of invasive electrophysiologic testing in patients with symptomatic bundle branch block.". Am J Cardiol 59 (8): 817-23. PMID 3825942.
  24. ↑ Ezri M, Lerman BB, Marchlinski FE, Buxton AE, Josephson ME (1983). "Electrophysiologic evaluation of syncope in patients with bifascicular block.". Am Heart J 106 (4 Pt 1): 693-7. PMID 6613815.
  25. ↑ Twidale N, Heddle WF, Ayres BF, Tonkin AM (1988). "Clinical implications of electrophysiology study findings in patients with chronic bifascicular block and syncope.". Aust N Z J Med 18 (7): 841-7. PMID 3250407.
  26. ↑ Englund A, Bergfeldt L, Rehnqvist N, Aström H, Rosenqvist M (1995). "Diagnostic value of programmed ventricular stimulation in patients with bifascicular block: a prospective study of patients with and without syncope.". J Am Coll Cardiol 26 (6): 1508-15. doi:10.1016/0735-1097(95)00354-1. PMID 7594078.
  27. ↑ Probst P, Pachinger O, Akbar Murad A, Leisch F, Kaindl F (1979). "The HQ time in congestive cardiomyopathies.". Am Heart J 97 (4): 436-41. PMID 425877.
  28. ↑ 28.0 28.1 Dhingra RC, Wyndham C, Bauernfeind R, Swiryn S, Deedwania PC, Smith T et al. (1979). "Significance of block distal to the His bundle induced by atrial pacing in patients with chronic bifascicular block.". Circulation 60 (7): 1455-64. PMID 498473.
  29. ↑ Cheng TO (1971). "Atrial pacing: its diagnostic and therapeutic applications.". Prog Cardiovasc Dis 14 (2): 230-47. PMID 4937704.
  30. ↑ Brignole M, Menozzi C, Moya A, Garcia-Civera R, Mont L, Alvarez M et al. (2001). "Mechanism of syncope in patients with bundle branch block and negative electrophysiological test.". Circulation 104 (17): 2045-50. PMID 11673344.
  31. ↑ Perloff JK, Stevenson WG, Roberts NK, Cabeen W, Weiss J (1984). "Cardiac involvement in myotonic muscular dystrophy (Steinert's disease): a prospective study of 25 patients.". Am J Cardiol 54 (8): 1074-81. PMID 6496328.
  32. ↑ Hiromasa S, Ikeda T, Kubota K, Hattori N, Nishimura M, Watanabe Y et al. (1987). "Myotonic dystrophy: ambulatory electrocardiogram, electrophysiologic study, and echocardiographic evaluation.". Am Heart J 113 (6): 1482-8. PMID 3591615.
  33. ↑ Stevenson WG, Perloff JK, Weiss JN, Anderson TL (1990). "Facioscapulohumeral muscular dystrophy: evidence for selective, genetic electrophysiologic cardiac involvement.". J Am Coll Cardiol 15 (2): 292-9. PMID 2299071.
  34. ↑ JAMES TN, FISCH C (1963). "OBSERVATIONS ON THE CARDIOVASCULAR INVOLVEMENT IN FRIEDREICH'S ATAXIA.". Am Heart J 66: 164-75. PMID 14051182.
  35. ↑ Roberts NK, Perloff JK, Kark RA (1979). "Cardiac conduction in the Kearns-Sayre syndrome (a neuromuscular disorder associated with progressive external ophthalmoplegia and pigmentary retinopathy). Report of 2 cases and review of 17 published cases.". Am J Cardiol 44 (7): 1396-400. PMID 506943.
  36. ↑ Charles R, Holt S, Kay JM, Epstein EJ, Rees JR (1981). "Myocardial ultrastructure and the development of atrioventricular block in Kearns-Sayre syndrome.". Circulation 63 (1): 214-9. PMID 7438396.
  37. ↑ JAMES TN (1962). "Observations on the cardiovascular involvement, including the cardiac conduction system, in progressive muscular dystrophy.". Am Heart J 63: 48-56. PMID 14451031.
v • d • e
Circulatory system pathology (I, 390-459)
HypertensionHypertensive heart disease - Hypertensive nephropathy - Secondary hypertension (Renovascular hypertension)
Ischaemic heart diseaseAngina pectoris (Prinzmetal's angina) - Myocardial infarction (heart attack) - Dressler's syndrome
Pulmonary circulationPulmonary embolism - Cor pulmonale
PericardiumPericarditis - Pericardial effusion - Cardiac tamponade
Endocardium/heart valvesEndocarditis - mitral valve (regurgitation, prolapse, stenosis) - aortic valve (stenosis, insufficiency) - pulmonary valve (stenosis, insufficiency) - tricuspid valve (stenosis, insufficiency)
MyocardiumMyocarditis - Cardiomyopathy (Dilated cardiomyopathy, Hypertrophic cardiomyopathy, Loeffler endocarditis, Restrictive cardiomyopathy) - Arrhythmogenic right ventricular dysplasia
Electrical conduction system
of the heart		Heart block: AV block (First degree, Second degree, Third degree) - Bundle branch block (Left, Right) - Bifascicular block - Trifascicular block
Pre-excitation syndrome (Wolff-Parkinson-White, Lown-Ganong-Levine) - Long QT syndrome - Adams-Stokes syndrome - Cardiac arrest - Sudden cardiac death
Arrhythmia: Paroxysmal tachycardia (Supraventricular, AV nodal reentrant, Ventricular) - Atrial flutter - Atrial fibrillation (Familial) - Ventricular fibrillation - Premature contraction (Atrial, Ventricular) - Ectopic pacemaker - Sick sinus syndrome
Other heart conditionsHeart failure - Cardiovascular disease - Cardiomegaly - Ventricular hypertrophy (Left, Right)
Cerebrovascular diseasesStroke - Transient ischemic attack - Intracranial hemorrhage/cerebral hemorrhage: Extra-axial hemorrhage (Epidural hemorrhage, Subdural hemorrhage, Subarachnoid hemorrhage)
Intra-axial hematoma (Intraventricular hemorrhages, Intraparenchymal hemorrhage) - Anterior spinal artery syndrome - Binswanger's disease - Moyamoya disease
Arteries, arterioles
and capillaries		Atherosclerosis (Renal artery stenosis) - Aortic dissection/Aortic aneurysm (Abdominal aortic aneurysm) - Aneurysm - Raynaud's phenomenon/Raynaud's disease - Buerger's disease - Vasculitis/Arteritis (Aortitis) - Intermittent claudication - Arteriovenous fistula - Hereditary hemorrhagic telangiectasia - Spider angioma - Dissection (Carotid artery, Vertebral artery)
Veins, lymphatic vessels
and lymph nodes		Thrombosis/Phlebitis/Thrombophlebitis (Deep vein thrombosis, May-Thurner syndrome, Portal vein thrombosis, Venous thrombosis, Budd-Chiari syndrome, Renal vein thrombosis, Paget-Schroetter disease) - Varicose veins / Portacaval anastomosis (Hemorrhoid, Esophageal varices, Varicocele, Gastric varices, Caput medusae) - Superior vena cava syndrome - Lymph (Lymphadenitis, Lymphedema, Lymphangitis)
OtherHypotension (Orthostatic hypotension) - Rheumatic fever
See also congenital (Q20-Q28, 745-747)
v • d • e
Electrocardiography
OverviewHistory of the EKG • EKG interpretation basics • Normal sinus rhythm
EKG ComplexesP wave • QRS complex • ST Segment • T wave • T wave alternans • Tombstone T wave • U wave

Osborn wave • H wave • K wave • Delta wave

NSSTW changes
EKG IntervalsPR Interval • QRS Interval • ST Interval • QT Interval
Conduction System & BradycardiaCardiac pacemaker • SA node • AV node• Bundle of His • Purkinje fibers • Sinus bradycardia • First Degree AV Block • Second Degree AV Block • Complete or Third-Degree AV Block • Concealed conduction • AV Junctional Rhythms • LBBB • LAHB • LPHB • RBBB • Trifascicular block
Atrial ArrhythmiasSinus tachycardia • Premature Atrial Contractions (PACs) • Ectopic Atrial Rhythm • Paroxysmal Atrial Tachycardia (PAT) • Paroxysmal Atrial Tachycardia (PAT) with Block • Multifocal Atrial Tachycardia (MAT) • Atrial Flutter • Atrial Fibrillation • Wandering atrial pacemaker
Ventricular ArrhythmiasDifferential Diagnosis of Tachycardia with a Wide QRS Complex • Accelerated Idioventricular Rhythm • Ventricular Parasystole • Premature Ventricular Contractions (PVCs) • Ventricular tachycardia • Ventricular Fibrillation • Sudden cardiac death
EKG Abnormalities in Disease StatesHypertrophy & Dilatation • Right atrial enlargement • Left atrial enlargement • Biatrial enlargement • Left Ventricular Hypertrophy • Right Ventricular Hypertrophy • Biventricular Hypertrophy •

Acute myocardial infarction • NSTEMI • STEMI • Tombstone ST elevation • Right ventricular myocardial infarction • Atrial infarction

Pre-excitation Syndromes • Wolff-Parkinson-White Syndrome • Lown Ganong Levine Syndrome • Mahaim Type Preexcitation

Cardiomyopathies • Arrhythmogenic Right Ventricular Dysplasia • Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy

Drug Effects on the EKG • Adenosine • β-blockers • Digitalis • Quinidine • Procainamide • Disopyramide • Lidocaine • Tocainide and Mexiletine • Phenytoin • Encainide, Flecainide and Propafenone • Amiodarone • Bretylium • Ca Channel Blockers • Phenothiazines • Tricyclic Antidepressants • Lithium

Congenital Heart Disease • Dextrocardia • Atrial Septal Defect • Ventricular Septal Defect • Tetralogy of Fallot • Conjoined Twins or Siamese Twins • Congenital heart block

Electrolyte Disturbances • Hyperkalemia • Hypokalemia • Hypercalcemia • Hypocalcemia • Nonspecific Changes

Other Heart Diseases • Pericarditis • Myocarditis • Tamponade • Heart Transplantation • Sick Sinus Syndrome • Long QT Syndrome

Inherited Disease • Brugada Syndrome

Systemic Diseases • CNS Disease • Cardiac Tumors

Heart Transplantation • EKG Changes in patient with Heart Transplantation

Exogenous Effects • Hypothermia • Chest Trauma • Insect Bites • Electric Injuries
Technical Issues and Potential Errors in InterpretationArtifacts • Lead Placement Errors • The EKG in a Patient with a Pacemaker • EKG in athletes
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