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The Significance of Bilateral Bundle Branch Block in the Preoperative patient* A Retrospective Electrocardiographic and Clinical Study in 30 Patients Gerald R. Berg, M.D. and Morris N . Kotler, M.D., M.R.C.P. (Edin.) Thirty patients with electrocardiographic evidence of bilateral bundle branch block (BBBB) underwent 36 surgical procedures. Despite an 83 percent incidence of significant cardiac dlease, the overall mortality was 10 percent. In no case was death attributable to complete heart block, though one patient was found at postmortem to have sdfered acute myocardial infarction. Patients with previous syncopal episodes showed no increased incidence of arrhythmias and no patient bad a documented Stokes-Adams attack. It would appear that the routine use of temporary cardiac pacemakers is not justified in the preoperative patient with presumed BBBB. However, since the factors that ultimately cause complete heart block are not known in patients with BBBB, constant cardiac monitoring is mandatory in the intraoperative and immediate postoperative period. he significance of disease of both bundle Tbranches has recently been appreciated with the finding that a significant proportion of patients with electrocardiographic evidence of bilateral bundle branch block ( BBBB ) will eventually develop complete heart, block.' In addition, a history of syncope or transient dizziness in these patients may indicate that episodes of heart block have occurred. The question then of how to manage the patient with BBBB (as defined by various electrocardiographic criteria below) who presents for elective minor and major surgery is an important one. To manage such patients properly, knowledge of the natural history of patients with BBBB undergoing surgery would be of value. It is the aim of this study to determine retrospectively from a group of patients with BBBB the incidence of intraoperative and postoperative cardiac abnormalities, particularly the development of complete heart block in response to surgical and anesthetic stress. 'From the Electrocardiogram Laboratory and Department of Medicine, Albert Einstein College of Medicine, Bronx, New York. The reports of approximately 25,000 ECGs taken at the Hospital of the Albert Einstein College of Medicine were reviewed for the presence of BBBB in patients scheduled for surgery. The ECG criteria for BBBB in our patients were as follows: a ) Right bundle branch block (RBBB), with major left axis deuiation (LAD);'-4 ( 1 ) QRS duration of 0.12 sec or more; ( 2 ) mean QRS axis in standard leads more negative than -30"; ( 3 ) the presence of a small R wave of at least 0.04 sec in duration in leads I1 and 111; ( 4 ) QRS configuration in V1 consisting of a notched R wave, rR', rSR' or rsR' complex. b ) Left bundle branch block (LBBB) with first degree h a r t block5 ( 1 ) QRS duration of 0.12 sec or more; ( 2 ) QRS configuration over left precordial leads consisting of a notched r wave, rR', rSR', or rsR' complex; ( 3 ) S-T segment and T wave changes in leads over the left ventricle and ( 4 ) PR interval greater than 0.20 sec. The charts of these patients were then assessed for: a ) the presence of significant underlying risk factors b ) history of syncope or dizziness c ) history of previous cardiac disease d ) abnormal physical findings e ) nature of operation f ) type of anesthesia Downloaded From: http://_jupcvss.chestpubs.org/pdfaccess.ashx?url=/data/journals/chest/21507/ on 05/07/2017 PREOPERATIVE SIGNIFICANCE OF BBBB Table 1-Age No. patients 2 Distribution 1 1 0 1 1 5 1 g ) intraoperative complications h ) postoperative course with emphasis on the development of arrhythmias, myocardial infarction, or Stokes-Adams attacks. This study group consisted of 30 patients (25 men and five women) who underwent a total of 36 operative procedures. The mean age of our patients was 68.8 (distribution in Table 1).The clinical data are recorded in Table 2. Underlying Risk Factors A significant proportion ( 83 percent of patients ) showed evidence of underlying cardiac or circulatory disease manifested by angina pectoris, congestive heart failure, arrhythmias, and syncope or dizziness (Table 2). The most common findings were hypertension and previous myocardial infarction. Of the noncardiac or noncirculatory risk factors, diabetes mellitus was most commonly found (23 percent ). One patient presented with muscular dystrophy, the significance of which will be discussed below. Of the two ECG patterns of BBBB mentioned above, 26 patients (87 percent) exhibited RBBB and major LAD and four patients (13 percent) exhibited LBBB and first degree heart block. Surgey and Anesthesia Thirty-six procedures were performed in 30 patients with one patient undergoing three separate procedures. Of the 36 procedures, 12 (33 percent) were considered major and 24 (66 percent) minor Table L P a t i e n t Material Number of patients Average Age Number of Surgical Procedures 30 68.8 years 36 Major Minor Evidence of associated cardiac or circulatory disease 25 History of myocardial infarction History of angina pectoris History of congestive heart failure History of cardiac arrhythmia Hypertension Prior dizziness or syncope Associated findings: Diabetes rnellitus Rheumatoid arthritis Muscular dystrophy Gout (arbitrarily defined by an anesthetic time of 20 minutes). Of the patient group, 18 (50 percent) underwent general anesthesia, seven ( 19 percent) spinal and 11 (31 percent) local anesthesia. Intraoperative Complications There were no inoperative deaths. Three patients developed hypotension and in one patient there was an episode followed by ventricular fibrillation, which responded to lidocaine ( Xylocaine ) and DC countershock. Postoperative Complications There were numerous overall medical and surgical complications; however, only half of the patients exhibited cardiac abnormalities: four patients (11 percent) exhibited arrhythmias, three (8.5 percent) experienced dizziness or syncope and eight (22 percent) exhibited ST-T wave changes on ECG. There were no documented cases of complete heart block, although the occurrence of heart block could not be entirely ruled out in one patient (see case report of patient 2 ) . There were three deaths. Only one appeared to be related directly to the surgery. Postmortem examination revealed a fresh thrombus occluding the right coronary artery and a six-day-old posterior myocardial infarction, ( which coincided with the day of operation). The other two patients died from non-cardiac causes; one succumbed to overwhelming sepsis and respiratory failure and another died on the 31st postoperative day after a prolonged period of severe electrolyte imbalance. It is noteworthy that all three patients were considered poor surgical risks preoperatively and all were operated upon under spinal anesthesia. In analyzing the group of three patients experiencing dizziness or syncope postoperatively, three were hypertensive preoperatively; one had n history of congestive heart failure; all were considered to have BBBB on the basis of RBBB and LAD; two underwent spinal anesthesia and one general anesthesia and all three underwent major surgical procedures. In the two patients with a preoperative history of dizziness or syncope undergoing a total of four procedures ( three local and one spinal anesthesia ) , complete heart block was not noted either intraoperatively or postoperatively. The following case reports illustrate some of the difficulties encountered in evaluating the postoperative course in patients with BBBB. CHEST, VOL. 59, NO. 1, JANUARY 1971 Downloaded From: http://_jupcvss.chestpubs.org/pdfaccess.ashx?url=/data/journals/chest/21507/ on 05/07/2017 BERG AND KOTLER FIGURE1. ( Case 2 ) . An example of the pattern of complete RBBB with left anterior parietal block (1) QRS duration is 0.15 sec; ( 2 ) Mean QRS axis -52"; ( 3 ) RSR' configuration in lead V1; ( 4 ) APC in lead AVR. A 75-year-old white man was well (except for a history of dyspnea on exertion on climbing three flights of stairs) when he presented with a fiveday history of dysuria, hesitancy and diminished urinary stream. He was admitted for acute urinary retention. Physical examination revealed: blood pressure UX)/90 mm Hg; pulse 80 and regular; a harsh basilar systolic ejection murmur, distended bladder and absent ( R ) testicle. Laboratory data were normal except for an ECG that revealed RBBB and major left axis deviation ( Fig 1) . Transurethal resection of the prostate was performed under spinal anesthesia with tetracaine (Pontocaine). There were no complications during the one hour and 15 minute procedure, but immediately postoperatively, the patient developed hypotension (blood pressure 120/80 mm Hg) and puke rate of 4O/minute. ECG during the episode revealed sinus bradycardia; the patient responded to the intravenous administration of atropine sulfate, (1.0 mg), with a return to previous blood pressure and pulse. Serial ECGs were unchanged and there was no elevation of serum glutamic onloacetic transaminase. Comment right cranial nerve VII palsy, scattered rhonchi, and a grade 2/6 basilar systolic murmur. Laboratory data were within normal limits except for an ECG showing RBBB and LAD ( Fig 2). Prior to surgery, she was found to have a right hydronephrotic kidney and she developed a transient episode of atrial fibrillation that subsided spontaneously. Myocardial infarction could not be detected and the patient underwent cholecystectomy and right nephrectomy under general anesthesia with nitrous oxide and halothane without intraoperative complications. Her postoperative course was complicated by multiple episodes of dizziness and syncope, associated with paroxysmal rapid atrial fibrillation, M y controlled with quinidine sulfate 200 mg qid. She was discharged in regular sinus rhythm. The patient was readmitted one year after her cholecystectomy with a history of multiple episodes of syncope associated with rapid atrial fibrillation, and persistence of BBBB (Fig 3). Her symptoms were finally controlled with digitalis and procaine amide. Comment Although the impression of the physicians in attendance was that of a vasovagal reaction to the pain and anesthesia, transient complete heart block could not be led out. This patient illustrates the fact that certain patients with BBBB may present postoperative complications that may be interpreted as Stokes-Adam attacks, but which are actually secondary to rapid arrhythmia. A 63-year-old white woman presented for elective cholecystectomy. Her past history indicated that she had "hypertension," frequent episodes of palpitations, dyspnea on exertion and Bell's palsy. Physical examination revealed an obese woman, blood pressure 220/110 mm Hg, pulse 88/minute and regular, a Wilson and associates? drew attention to the unusual electrocardiogram of RBBB and major LAD and subsequent investigators2.0 found extensive involvement of both left and right bundle branches in patients displaying this pattern. Grant* CHEST, VOL. 59, NO. 1, JANUARY 1971 Downloaded From: http://_jupcvss.chestpubs.org/pdfaccess.ashx?url=/data/journals/chest/21507/ on 05/07/2017 PREOPERATIVE SIGNIFICANCE OF BBBB FIGURE2. (Case 29). An example of complete RBBB with LAD in a patient with palpitations: ( 1 ) QRS duration of .12 sec; ( 2 ) mean QRS axis of -43"; ( 3 ) P-R interval of .20. found that the marked LAD was attributed to involvement of the anterior superior division of the left bundle by either d i h s e fibrosis ("left anterior parietal block'.') or by microscopic infarcts ("left anterior peri-infarction block). The work of Mahairne and Lenegre2 have complemented these observations and show that complete atrioventricular block may result from lesions involving both bundles, but sparing the common bundle. . Several studies have demonstrated the various ECG presentations of disease of both bundle branches.2.4-7.9.10 Thus, anatomic BBBB has been correlated with: 1. Left bundle branch block masquerading as right bundle branch block, (complete LBBB in the limb leads and complete RBBB in the precordial leads ) .10 2. Alternating bundle branch block (either in the FIGURE3. ( Case 29). With LAD and RBBB during episode of dizziness. Patient now manifests: ( 1 ) rapid atrial fibrillation, ( 2 ) QRS 0.12, (3) mean QRS axis of -70". CHEST, VOL. 59, NO. 1, JANUARY 1971 Downloaded From: http://_jupcvss.chestpubs.org/pdfaccess.ashx?url=/data/journals/chest/21507/ on 05/07/2017 BERG AND KOTLER same or different tracings, beats of both the LBBB and RBBB type are present)." 3. Complete RBBB.and major LAD.',' 4. RBBB with major RAD implying a lesion of the posterior ramus of the left bundle and characterized by: a ) QRS pointing inferiorly and to the right at greater than +120°, b ) presence bf S in I and Q in 111 and, c ) large R waves in 11, 111 and aVF.4 5. QRS greater than 0.12 sec whether the pattern suggests RBBB or LBBB or is of the anomalous or atypical intraventricular block type, plus first degree heart block."." While this last pattern is not invariably associated with bilateral bundle branch disease, the association is consistent enough to be considered suspicious of such disease. Of the five ECG patterns mentioned, only the third (RBBB and LAD) is relatively common having been observed in 1 percent of routine hospital records in two large series'," and in 26 of 30 preoperative patients with BBBB in our series. The frequency of the association of RBBB and the involvement of the anterior superior division of the left bundle is explained by the proximity of these portions of the cardiac conduction system to the anterior portion of the intraventricular septum at which point a common blood supply from the left anterior descending artery is shared. 1 1 The etiology of BBBB is highly variable and is summarized by the clinico-pathologic study of Lenegre.? Of his 62 patients with histologic BBBB: a ) 39 exhibited coronary atherosclerosis ( 13 with hypertension and 28 with evidence of myocardial infarction ), b ) seven exhibited aortic valve disease, c ) two (the youngest patients in the series) had muscular dystrophy and d ) the remaining 19 patients had no apparent etiology for the sclerosis seen in the conduction system. An even lower incidence of clinichl cardiac disease was noted in a more recent study:' in which only 50 percent of 65 patients exhibited cardiac symptoms ( only criteria used). Other less common etiologies of BBBB such as idiopathic myocardopathyl2 and Chagas diseaselz{have been described as well. In our present series a larger proportion of patients had evidence of heart disease ( 83 percent), though postmortem studies were available in only one patient. Of note is case 6, the youngest patient in our series, who presented with muscular dystrophy. The association of muscular dystrophy and the pattern of RBBB and LAD has recently been reported in a patient with external ophthalmoplegia (considered a variant of muscular dystrophy by the author,'.' ) and the abnormalities of the conduction system found in muscular dystrophy have been well described. 1" It is estimated that 10 percent of patients with the pattern of RBBB and LAD will develop complete heart block.' It should be noted that the pattern of RBBB and RAD carries a significantly poorer prognosis since 75 percent of 28 patients exhibiting that pattern in Rosenbaum's series4 developed complete heart block. The question then of what clinical factors precipitate complete heart block in patients with RBBB must be assessed in light of the present series of patients. In general, either extension of the underlying fibrotic process or superimposed myocardial infarction would be the factors most likely to precipitate complete heart block. However, in the absence of these events, major surgical stress with its attendant hypotension, anesthesia, fluid depletion, acid-base and electrolyte imbalance may theoretically tip the delicate balance and throw a patient with BBBB into complete heart block. It would appear from the data collected in the present series that this combined stress was not sufficient to precipitate complete heart block in our patients. iVhether such patients will develop complete heart block in the future cannot be answered from the data presented, but it would seem a measure such as placement of pacemakers prophylactically in such patients, particularly those without a history of prior syncopal episodes, is not warranted at this time. Despite the apparent benignity of BBBB in our patients, the natural history of the disease necessitates careful preoperative evaluation with emphasis on selection of appropriate operative and anesthetic technique. Routine postoperative care should include careful continuous cardiac monitoring (even in patients undergoing minor procedures) in an attempt to recognize the early development of potentially fatal heart block. 1 Laser RE, Haft JI, Friedberg CK: Relationship of right bundle branch block and marked left axis deviation (with left parietal or periinfarction block) to complete heart block and syncope. Circulation 37:429, 1968 2 Lenegre J : Etiology and pathology of bilateral bundle branch block in relation to complete heart block. Progr Cardiovasc Dis 6:409, 1964 3 Watt TJ Jr, Pruitt RD: Character, cause and consequence of combined left axis deviation and right bundle branch block in human electrocardiograms. Amer Heart J 77:460, 1969 4 Rosenbaum hlB: Types of right brindle branch block and their clinical significance Electrocardiol 1 :221, 1968 5 hlcNally EM, Benchimol A: lledical and physiological considerations in the use of artificial cardiac pacing, Part I . Amer Heart J 75:380, 1968 6 htahaim 1: Les htaladies Organiques du Faisceau de His- CHEST, VOL. 59, NO. 1, JANUARY 1971 Downloaded From: http://_jupcvss.chestpubs.org/pdfaccess.ashx?url=/data/journals/chest/21507/ on 05/07/2017 PREOPERATIVE SIGNIFICANCE OF BBBB 7 8 9 10 Tawara, Paris, Maison et Cie, 1931 Wilson FN, Johnson FD, Barker PS: Electrocardiogram of an unusual type in right bundle branch block. Amer Heart J 9:472, 1934 Grant RP: Left axis deviation: An electrocardiographic pathological correlation. Circulation 14:233, 1956 Lepeschkin E: The electrocardiographic diagnosis of bilateral bundle branch block in relation to complete heart block. Progr Cardiovasc Dis 6:445, 1964 Unger PN, Lesser ME, Kugel VH, et al: Concept of masquerading bundle branch block: An electrocardiographic pathologic correlation. Circulation 17:397, 1958 11 James TN: The coronary circulation and conduction sys- 12 13 14 15 tem in acute myocardial infarction. Prog Cardiovasc Dis 10:410, 1968 Case Records of the hlassachusetts General Hospital. New Eng J hled 275:550, 1966 Rosenbaum MB: Chagasic myocardiopathy. Prog Cardiovasc Dis 7 :199, 1964 Ross A, 1-ipschutz B, Austin J, et al: External Ophthalmoplegia and complete heart block. New Eng J \led 280:313, 1969 James TN: Observations on the cardiovascr~lar involvement including the cardiac conduction system in progressive muscular dystrophy. Amer Heart 63:48, 1962 Reprint requests: Dr. Moms Kotler, Sinai Hospital, Baltimore 21215 Hedonism by Force of Circumstances T h e Middle Ages, immersed in heaving seas of trouble, and lifted heavenward by great spiritual emotions, had scant breathing space for the cultivation of nerves. Men endured life and enjoyed it. Their endurance and enjoyment were unimpaired by the violence of their fellow men or the vision of an angry Fate. Cruelty, which w e cannot bear to read about, and a hell, which w e will not bear to think about, failed signally to curb the zest with which they lived their days. There is no reason to suppose that Dante, whose fervid faith compassed the redemption of mankind, disliked his dream of hell, or that it irked him to consign to it so many eminent and agreeable people. T h e Renaissance gave itself un- reservedly to all the pleasures that could b e extracted from the business of living. If the men and women who lived through those highly colored, harshly governed days had fretted too persistently over the misfortune of others, or had spent their time questioning the moral intelligibility of life, the Renaissance would have failed of its fruition, and the world would b e a less engaging place for us to live in now. Repplier A: T h e Divineness of Discontent, in Connolly FX (editor) :Literature, the Channel of Culture. New York, Harcourt, Brace, 1948 CHEST, VOL. 59, NO. 1, JANUARY 1 9 7 1 Downloaded From: http://_jupcvss.chestpubs.org/pdfaccess.ashx?url=/data/journals/chest/21507/ on 05/07/2017