What s New in IV Conduction? (Quadrafascicular, not Trifascicular)
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1 What s New in IV Conduction? (Quadrafascicular, not Trifascicular) Frank Yanowitz, MD Professor, University of Utah School of Medicine Medical Director, IHC ECG Services (Urban Central Region) etc I have no disclosures
2 Case: 59 year old man with worsening exertional chest pain 26-Dec-2015: ER presentation; admit with unstable angina 27-Dec-2015: Stress PET scan showed large, reversible perfusion defect anterior, anteroseptal, anterolateral regions 28-Dec-2015: Coronary angio: 95% distal left main, 100% mid-lad, and 95% ostial L-Cx 29-Dec-2015: ECHO: severe LV dysfunction; EF 20% CABG: LIMA to LAD, two saphenous grafts to obtuse branches 2-Jan-2016: Discharged
3 KM: 59 year old man; 26 Dec 2015 (admission) NSR; HR 70; PR 160 ms; QRS 110 ms; QT 400 ms; QRS axis -15 NSR, Anteroseptal MI; ST-T abnormalities
4 KM: 59 year old man; 29 Dec 2015 (post-op) NSR; HR 90; PR 170 ms; QRS 120 ms; QT 440 ms; QRS axis -40 ; ST-T abnormalities; PAF (Prominent Anterior Forces) Differential Diagnosis???
5 KM: 59 year old man; 1 Jan 2016 Time to go home! NSR; HR 80; PR 120 ms; QRS 110 ms; QT 360 ms; QRS axis -20 ; ST-T abnormalities PAF no longer present!
6 Differential Diagnosis of PAF (R/S ratio in V1 or V2 1) Normal variant: marked counterclockwise rotation (~1% prevalence) Misplaced precordial leads Dextrocardia with situs inversus Right ventricular and biventricular hypertrophy, True posterior myocardial infarction (new terminology: lateral MI) WPW type A (posterior located accessory pathways) Complete and incomplete RBBB (rsr with large R waves) Hypertrophic cardiomyopathy Muscular dystrophy (Duchenne s) Left septal fascicular block (LSFB). What s this?
7 What are those big R-waves in V1-3?? They may represent Left Septal Fascicular Block, dear
8 Los Hemibloqueos RAD LAD (I met him in 1969)
9 -60 Classic LAFB rs complex in II, III, avf S in III > S in II small q in I and/or avl R in avl > R in avr LAD: - 45 to - 90
10 GN: 63 y.o. man (severe CHD, biventricular failure) +150 Diagnosis: RBBB + LPFB + Old IWMI rs in I, avl R in III > R in II qr in II, III, avf LPFB q in III > q in II (if IWMI, q 40 ms) QRS axis +150 R/O isolated right heart disease Notch in descending limb of R in III
11 Suano Tawara, MD
12 Human heart dissected by Dr. Rosenbaum Left Anterior Fascicle Left Bundle Left Posterior Fascicle
13 Variations on a LBB Theme LBB anatomy in 20 normal hearts Br Heart J 1972;34: ~65% human hearts have a third fascicle in the left bundle
14 Durrer et al (Circulation 1970;41:899): (7 isolated human hearts) Earliest activation of LV: (870 sites) Anterior paraseptal area (below MV) left anterior fascicle Posterior paraseptal area.. left posterior fascicle Central (mid) left septal surface.. left septal fascicle
15 Review Article 2003 (India) 2008;8: (India) Ann Noninvasive Electrocardiol 2011;16: (International)
16 Brazil Canada Just Published: 2016
17 ECG Criteria for LSFB: Prominent Anterior Forces (PAF) Normal frontal plane QRS axis Normal QRS duration (up to 110 ms) Increased intrinsicoid deflection V 1,2 R in V 1 > 5mm S in V 2 <5mm R/S ratio in V 1,2 >2 PAF R in V2 >15 mm 35 ms R increasing V 1 to V 3 ; decreasing V 5,6 Small q-waves in V 2,3 AND Clinically, exclude other causes of PAF
18 KM: 59 year old man; 29 Dec 2015 (post-op) Normal frontal plane QRS axis Normal QRS duration (up to 110 ms) Increased intrinsicoid deflection V 1,2 R in V 1 > 5mm S in V 2 <5mm R/S ratio in V 1,2 >2 R in V2 >15 mm R increasing V 1 to V 3 ; decreasing V 5,6 Small q-waves in V 2,3 HR 90; PR 170 ms; QRS 120 ms; QT 440 ms; QRS axis -40 ; ST-T abnormalities; PAF (Prominent Anterior Forces)
19
20 Another case of LSFB Courtesy of: Dr. Andres Ricardo Perez Riera
21
22 54 y.o. man with Class II angina: Exercise ECG test Hypertension Hyperlipidemia Uchida et al. Indian Pacing and EP Journal 2006;6:135
23 54 y.o. man with Class II angina: C-Angio
24 10/22/2012: 44 year old man with severe aortic stenosis and bicuspid valve (pre-op ECG) ECG Diagnosis: 1) LAE; 2) LPFB + LSFB (left bifascicular block); 3) LVH with strain
25 LSFB: Etiologies Coronary artery disease (left main and LAD distribution) Chronic Chagas cardiomyopathy (main cause of LSFB in Latin America Hypertrophic Obstructive Cardiomyopathy (HOCM) Non-obstructive cardiomyopathy Aging conduction disease (Lev s disease) Aortic valve disease Others
26 Normal frontal plane QRS axis (yes) Normal QRS duration (up to 110 ms) (yes) Increased intrinsicoid deflectionv 1,2 (yes) R in V 1 > 5mm (yes) S in V 2 <5mm (no) R/S ratio in V 1,2 >2 (yes) R in V2 >15 mm (yes) R increasing V 1 to V 3 ; decreasing V 5,6 (yes) Small q-waves in V 2,3 (yes) Absent q-wave in V5-6, I (yes) 51 year old man with PAF: no history of heart disease HR 67 bpm; PR 160 ms; QRS 106 ms; QRS axis -24
27 Normal frontal plane QRS axis (yes) Normal QRS duration (up to 110 ms) (yes) Increased intrinsicoid deflectionv 1,2 (yes) R in V 1 > 5mm (yes) S in V 2 <5mm (no) R/S ratio in V 1,2 >2 (yes) R in V2 >15 mm (yes) R increasing V 1 to V 3 ; decreasing V 5,6 (yes) Small q-waves in V 2,3 (no) Absent q-wave in V5-6, (no) 24 year old man with PAF: no history of heart disease HR 78 bpm; PR ms; QRS 102 ms; QRS +71axis
28 What are those big R-waves in V1-3?? They may represent Left Septal Fascicular Block, dear
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