Abstract
Despite the bulk of anatomical and histologic evidence supporting the existence of three fascicules in the left branch of the His bundle, the concept of a bifascicular system proposed by Rosenbaum and his school has been adopted by the cardiological community as a practical teaching tool. Left anterior hemiblock (LAH) refers to block of the antero-superior branch of the left branch which is small and left posterior hemiblock (LPH) to block of the postero-inferior branch which is larger. The LAH is more common that the LPH and often associated with a complete right bundle branch block (RBBB). Coronary artery disease (CAD) is a major cause of hemiblocks. In this review article, we discuss various aspects of the relation of hemiblocks with CAD. We looked at the prevalence of LAH in consecutive patients undergoing coronary angiography and who had a significant coronary lesion in one vessel or more. In all patients with LAH, a significant lesion of the left anterior descending coronary artery was present, with in the majority of patients, an impairment of the left ventricular function. Bifascicular block (RBBB with LAH or LPH) can complicate acute myocardial infarction and is often associated with a poor prognosis and the presence of heart failure. Thrombolysis and or early angioplasty in acute myocardial infarction have significantly improved the prognosis and reduced the mortality associated with bifascicular block. Left anterior hemiblock pattern was also observed during angina pectoris occurring at rest or induced by exercise or atrial pacing. In these circumstances, LAH is transient and is likely to be due to ischemia in the anterolateral wall related to a lesion of the main trunk or the proximal left anterior descending coronary artery with the postero-inferior wall being first depolarized. The presence of bifascicular block in acute myocardial infarction still is associated with an unfavorable prognosis as compared to non-bundle branch block patients because of the common association with heart failure and other comorbidities.
Similar content being viewed by others
References
Riera AR, Uchida AH, Schapachnik E, Dubner S, Zhang L, Filho CF, et al. The history of left septal fascicular block: chronological considerations of a reality yet to be universally accepted. Indian Pacing Electrophysiol J. 2008;8:114–28.
Fisher J. Hemiblocks and the fascicular systems: myths and implications. J Interv Cardiac Electrophysiol. 2018. https://doi.org/10.1007/s10840-018-0440-1.
Elizari MV, Acunzo RS, Ferreiro M. Hemiblocks revisited. Circulation. 2007;115:1154–63.
Rosenbaum MB. The hemiblocks: diagnostic criteria and clinical significance. Mod Concepts Cardiovasc Dis. 1970;39:141–6.
Rosenbaum MB, Elizari MV, Levi RJ, Nau GJ, Pisani N, Lázzari JO, et al. Intraventricular trifascicular blocks. The syndrome of right bundle branch block with intermittent left anterior and posterior hemiblock. Am Heart J. 1969;78(3):306–17.
Castellanos A Jr, Chahine RA, Chapunoff E, Portillo B, Gomez J. Diagnosis of left anterior hemiblock in the presence of inferior wall myocardial infarction. Chest. 1971;60:543–51.
Castellanos A Jr, Myerburg RJ. The hemiblocks in acute myocardial infarction. New York: Appleton-Century-Crofts; 1976.
Lévy S, Gérard R, Castellanos A Jr, Gharhamani A, Sommer LS. Pure left anterior hemiblock: hemodynamic and arteriographic aspects in patients with coronary artery disease. Eur J Cardiol. 1978;8:553–63.
Lévy S, Castellanos A Jr, Arcebal A, Lemberg L. Right bundle-branch block with left hemiblock in the acute phase of myocardial infarction. Prognosis and role of cardiac pacing. Arch Mal Coeur Vaiss. 1975;68:497–504.
Castellanos A Jr. Diagnosis of left anterior hemiblock and left posterior hemiblock in the presence of inferior wall myocardial infarction. Bull N Y Acad Med. 1971;47(8):923–30.
Lenègre J. Etiology of bilateral bundle branch fibrosis in relation to complete heart block. Prog Cardiovasc Dis. 1964;6:17–320.
Lev M. The pathology of complete atrioventricular block. Prog Cardiovasc Dis. 1964;6:320–6.
Hoffman I, Mehta J, Hilsenrath J, Hamby RI. Anterior conduction delay: a possible cause for prominent anterior QRS forces. J Electrocardiol. 1976;9:15–21.
Reiffel JA, Bigger JT Jr. Pure anterior conduction delay: a variant “fascicular” defect. J Electrocardiol. 1978;11:315–9.
Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). Lancet. 1986;1(8478):397–402.
The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329:673–82.
Grüntzig A, Kumpe DA. Technique of percutaneous transluminal angioplasty with the Grüntzig balloon catheter. AJR Am J Roentgenol. 1979;132:547–52.
Hartzler GO, Rutherford BD, McConahay DR, et al. Percutaneous transluminal coronary angioplasty with and without thrombolytic therapy for treatment of acute myocardial infarction. Am Heart J. 1983;106:965–73.
Weaver WD, Simes RJ, Betriu A. Et al for the primary coronary angioplasty vs. thrombolysis collaboration group. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative overview. JAMA. 1997;278:2093–8.
Zhang H, Goodman SG, Steg G, Budaj A, Lopez-Sendon J, Dorian P, et al. Clinical significance of left anterior hemiblock in acute coronary syndromes. Can J Cardiol. 2013;29:S295–6. (Abstract)
Wong CK, Stewart RA, Gao W, French JK, Raffel C, White HD. Prognostic differences between different types of bundle branch block during the early phase of acute myocardial infarction: insights from the Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial. Eur Heart J. 2006;27:21–8.
Sgarbossa EB, Pinski SL, Topol EJ, Califf RM, Barbagelata A, Goodman SG, et al. Acute myocardial infarction and complete bundle branch block at hospital admission: clinical characteristics and outcome in the thrombolytic era. J Am Coll Cardiol. 1998;31:105–10.
Newby KH, Pisanó E, Krucoff MW, Green C, Natale A. Incidence and clinical relevance of the occurrence of bundle-branch block in patients treated with thrombolytic therapy. Circulation. 1996;94:2424–8.
Nguyen HL, Lessard D, Spencer FA, Yarzebski J, Zevallos JC, Gore JM, et al. Thirty-year trends (1975–2005) in the magnitude and hospital death rates associated with complete heart block in patients with acute myocardial infarction: a population-based perspective. Am Heart J. 2008;156:227–33.
Melgarejo-Moreno A, Galcerá-Tomás J, Consuegra-Sánchez L, Alonso- Fernández N, Díaz-Pastor Á, Escudero-García G, et al. Relation of new permanent right or left bundle branch block on short and long-term mortality in acute myocardial infarction bundle branch block and myocardial infarction. Am J Cardiol 2015;116:1003–9.
Lévy S, Gérard R, Castellanos A, Gharhamani AR, Sommer LS. Transient left anterior hemiblock during angina pectoris: coronagraphic aspects and clinical significance. Eur J Cardiol. 1979;9:215–25.
Lévy S, Blanc A, Clémenty J, Besse P, Dallocchio M, Bricaud H. Isolated left anterior hemiblock during attacks of angina pectoris. Arch Mal Coeur Vaiss. 1978;71:801–7. (French.)
Oliveros RA, Seaworth J, Weiland FL, Boucher CA. Intermittent left anterior hemiblock during treadmill exercise test. Chest. 1977;72:492–4.
Levy S, Bouvier E, Chanudet X, Besse P, Clementy J, Bricaud H. Left anterior fascicular block secondary to coronary artery spasm. Eur Heart J. 1981;2:117–22.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lévy, S. Bundle branch blocks and/or hemiblocks complicating acute myocardial ischemia or infarction. J Interv Card Electrophysiol 52, 287–292 (2018). https://doi.org/10.1007/s10840-018-0430-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10840-018-0430-3