Cardiac incoordination induced by left bundle branch block: its relation with left ventricular systolic function in patients with and without cardiomyopathy

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Abstract

Left bundle branch block (LBBB) alters the pattern of electrical activation of the heart1-4 and disturbs the left ventricular (LV) systolic function1, 5-7 even in absence of other cardiovascular diseases8. The presence of LBBB in patients with dilated (DCMP) or ischemic cardiomyopathy (ICMP) implies a progressive worsening of the LV systolic function and prognosis9-13. In these patients cardiac resynchronization therapy (CRT) improves short- and long-term hemodynamics, functional capacity, quality of life and survival14-18. However, even following simple electrocardiographic and echocardiographic selection criteria for CRT19, 20 one third to one fourth of the patients do not respond to or even worsens after CRT17, 21-23. Consequently, different techniques, including Tissue Doppler echocardiography (TDE) have been used to detect inter and intra-ventricular cardiac dyssynchrony, to evaluate its effects on LV systolic function, and to assess the effects of CRT24-28. Although a delayed mechanical contraction of some LV walls plays an important role in the LV hemodynamics, it is less known how a delayed electrical activation might affect the process of myocardial coordination (MC), defined as the synchronicity of time-related events occurring before mechanical contraction and ventricular filling, and how an alteration in MC might affect the LV contraction and hemodynamics. The present study was thus designed to assess the physiological basis of MC in patients with LBBB with or without DCMP or ICMP by means of TDE.

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Patients and controls: The studied population consisted of 86 individuals: 21 with isolated LBBB but otherwise healthy, 26 patients with DCMP and LBBB, 19 patients with ICMP and LBBB, and 20 healthy individuals (Controls). The controls, being part of a study in the geriatric population29, were asymptomatic without treatment with cardiovascular pharmacological agents and had a normal rest ECG, a normal standard echocardiogram, and a normal exercise test. Individuals with LBBB were also asymptomatic and were recruited from an ECG-database; none of them were on treatment with cardiovascular pharmacological agents and all of them had been referred to a rest ECG as a routine procedure before a noncardiovascular surgical intervention. Among patients with DCMP and ICMP, 84% were on treatment with diuretics, 78% were on beta-blocker agents, 72% were on angiotensine converting enzyme inhibitors or angiotensine II receptor blockers, 67% were on aspirin, 42% on digoxin, and 34% on oral anticoagulants. All participants gave a written consent and the ethical committee at the Karolinska University Hospital, Huddinge, approved the study.

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