Diagnostic criteria for proximal left bundle branch block and their significance in predicting the success of cardiac resynchronization therapy

Abstract

Aim. To develop diagnostic criteria for proximal left bundle branch block (LBBB) based on non-invasive methods and to determine the significance of these criteria in predicting the effect of cardiac resynchronization therapy (CRT).Material and methods. To develop criteria, 58 patients (21 men, mean age, 76,1±7,1 years) with LBBB occurred immediately after transcatheter aortic valve implantation (TAVI) were included. To assess the significance of the developed criteria, the second group included 22 patients (11 men, mean age, 57,9±9,3 years) with dilated cardiomyopathy (DCM), who had indications for CRT. The effectiveness of CRT was assessed by echocardiography 6 months after implantation. All patients in the DCM group and 15 patients in the TAVI group underwent superficial epiand endocardial non-invasive mapping using Amycard 01C EP Lab (EP Solutions SA, Switzerland). Patients in the DCM group underwent contrast-enhanced cardiac magnetic resonance imaging (MRI) before device implantation.Results. The criteria for proximal LBBB included 3 electrocardiographic features: QRS complex >130 ms in women and 140 ms in men, QSor rS-configuration in V1 lead, notch in two or more lateral leads (I, avL, V5, V6), and 2 mapping criteria: characteristic location of block line and delayed activation point. In the DCM group, the criteria were positive in 13 of 22 patients (59%). The developed criteria for proximal LBBB showed a relatively strong, significant relationship with the positive effect of CRT (сhi-square test =5,46, p=0,02, Cramer test =0,5, odds ratio (OR)=15,0, 95% confidence interval (CI), 1,32-169,9, p=0,002). An additional analysis showed that both the criteria for proximal block and CRT effect are associated with myocardial fibrosis according to MRI. In particular, intramural stria-shaped contrast accumulation in the interventricular septum leads to a change in characteristic of proximal block mapping phenomena — displacement of delayed activation point (chi-square test =13,9, p<0,001, Cramer test =0,79) and displacement or absence of conduction block lines (chi-square test =6,92, p=0,009, Cramer test =0,56) and prevents the CRT effect (OR =8,67, 95% CI, 1,05-71,57 p=0,03).Conclusion. Proximal LBBB is only one of the factors determining the effectiveness of CRT. Proximal LBBB may mask significant myocardial structural changes that prevent the CRT success.

Keywords

• left bundle branch block
• proximal left bundle branch block
• noninvasive mapping
• dilated cardiomyopathy
• heart failure
• cardiac resynchronization therapy
• contrast-enhanced cardiac magnetic resonance
• myocardial fibrosis
• transcatheter aortic valve implantation