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Editorial

The Importance of Electrovectorcardiographic Assessment of Intraventricular Blocks and their Relationship with the Cardiac Cycle

The impact of intraventricular conduction disorders on myocardial activation and ventricular function has long been debated. However, with the advent of cardiac resynchronization therapy, this topic has gained even more attention during the last two decades.^,

At that time, our team utilized surface electrocardiographic mapping and isochronal line maps to assess the mean activation time in three specific regions of the heart: the right ventricle (RV), the left ventricle (LV), and the anteroseptal region. This evaluation was conducted on patients with a left ventricular ejection fraction of less than 40%, who exhibited left bundle branch block (LBBB), and had a mean QRS duration of 180 ms.^, The cardiac electrical activation was evaluated in three groups of patients: 1) patients with native LBBB, 2) patients under RV pacing, and 3) patients under biventricular pacing (BVP). In individuals with LBBB, the RV and anteroseptal mean activation time were delayed compared to the LV, leading to a loss of synchrony. Similarly, the RV pacing group’s activation time extended beyond normal, with a more significant difference between the septal area and LV. LV and RV activation times were similar during BVP, and the septal activation approached the normal and native LBBB conditions. Those findings suggested that the prolonged RV electrical activation by BVP, which sometimes may go unnoticed in the presence of LBBB, could be a relevant criterion in selecting candidates for cardiac resynchronization therapy.^,

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Research Letter

An Unusual Manifestation of Rejection

Carlos Xavier Correia de Resende et al. Pedro Grilo Diogo Sandra Amorim Gonçalo Pestana … José Pinheiro Torres Filipe Macedo

Introduction

Orthotopic heart transplantation is the current treatment of choice for selected patients with end-stage heart failure. With the improvement of surgical techniques and the efficiency of new immunosuppressive treatments, short-term survival has markedly improved throughout the years. However, these patients still suffer from important comorbidities caused by chronic transplant complications such as rejection, coronary allograft vasculopathy (CAV) and malignancy. Rhythm disorders are common in heart transplant patients and in some circumstances, they can be the first clinical manifestation of rejection. Coronary vasospasm has been recently associated with acute rejection and CAV, but the mechanisms underlying this phenomenon are still speculative.

We present a clinical case of acute heart transplant rejection, manifested by coronary vasospasm and advanced rhythm disorder.

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Original Article

Correlation between Cardiomegaly on Chest X-Ray and Left Ventricular Diameter on Echocardiography in Patients with Chagas Disease

Matheus Rassi Fernandes Ramos et al. Henrique Turin Moreira Gustavo Jardim Volpe Minna Romano … Benedito Carlos Maciel André Schmidt Anis Rassi Junior Jose Antônio Marin Neto

Abstract

Background

Cardiomegaly on chest X-ray is an independent predictor of death in individuals with chronic Chagas cardiomyopathy (CCC). However, the correlation between increased cardiothoracic ratio (CTR) on chest X-ray and left ventricular end-diastolic diameter (LVEDD) on echocardiography is not well established in this population.

Objectives

To assess the relationship between chest X-ray and LVEDD on echocardiography in patients with Chagas disease and its applicability to the Rassi score.

Methods

Retrospective study on 63 Chagas disease outpatients who underwent chest X-ray and echocardiography. Cardiomegaly on chest X-ray was defined as a CTR>0.5. LVEDD was analyzed as a continuous variable. ROC curve was used to evaluate the ability of LVEDD in detecting cardiomegaly by chest X-ray, with a cut-off point defined by the highest sum of sensitivity and specificity.

Results

Median age 61 years [interquartile range 48-68], 56% were women. CCC was detected in 58 patients, five patients had the indeterminate form of Chagas disease. Cardiomegaly was detected in 28 patients. The area under the ROC curve for LVEDD was 0.806 (95%CI: 0.692-0.919). The optimal cut-off for LVEDD was 60 mm (sensitivity = 64%, specificity = 89%). The use of LVEDD on echocardiography as a surrogate for CTR on chest X-ray changed the Rassi score values of 14 patients, with a reduction in the presumed risk in 10 of them.

Conclusion

LVEDD on echocardiography is an appropriate, highly specific parameter to distinguish between the presence and absence of cardiomegaly on chest X-ray in Chagas disease. (Arq Bras Cardiol. 2021; 116(1):68-74)

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Case Report

Painful Left Bundle Branch Block Syndrome in a Patient Referred to Electrophysiologic Study: A Case Report

José Nunes de Alencar Neto et al. Marcel Henrique Sakai Saulo Rodrigo Ramalho de Moraes Elano Sousa da Frota … Claudio Cirenza Angelo Amato Vincenzo de Paola

Introduction

The development of chest pain associated with intermittent left bundle branch block (LBBB) in the absence of coronary artery disease has been described in the literature as painful left bundle branch block syndrome. The mechanism responsible for the chest pain is unknown, but the main current hypothesis is related to acute cardiac dyssynchrony.

In this syndrome, the LBBB occurs when the cycle length is equal to or less than the refractory period of the left bundle, mainly during physical effort. The chest pain in the case of the painful LBBB syndrome may range from a mild discomfort to a disabling condition.

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Artigo Original

Exercise-induced left bundle branch block: prevalence and prognosis

Ricardo Stein et al. Michael Ho Cristiano Machado Oliveira Jorge Pinto Ribeiro … Kusum Lata Joshua Abella Harald Olson Jonathan Myers Victor Froelicher

BACKGROUND: Exercise-induced left bundle branch block (EI-LBBB) is an infrequent finding. Its prevalence and prognostic significance are not clear. OBJECTIVE: To evaluate, in a longitudinal study, the prevalence and prognostic significance of EI-LBBB in American war veterans. METHODS: We evaluated 9,623 patients submitted to an exercise test (ET) in treadmill between 1987 and 2007. The outcomes were compared between those with normal TE, the ones with EI-LBBB and the ones with down-sloping ST-segment. Mortality and causes of death were identified while blinded to the ET results. RESULTS: In this prospective cohort, 6,922 individuals had normal ET results (57.2 ± 11.4 years), 1,739 had abnormal ST-segment depression (62.7 ± 9.8 years), and 38 had EI-LBBB (65.2 ± 11.9 years). The prevalence of EI-LBBB was 0.38%. After 8.8 years, there were 1,699 deaths due to all-cause mortality and 610 cardiovascular (CV) deaths; coronary artery disease and heart failure were more prevalent in patients with EI-LBBB. Patients with EI-BCRE had a hazard ratio of 2.37 (p = 0.002) for all-cause mortality, but it was not significant when adjusted for age or when the CV death was the assessed outcome. CONCLUSION: EI-LBBB is a rare clinical finding. Individuals with BCRE-EI have higher all-cause mortality when compared to those with normal ET results. However, this fact is explained by the fact that these patients are significantly older and have more associated cardiovascular diseases.

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Artigo Original

Ventricular remodeling in right ventricular apical pacing

Rodrigo Tavares Silva et al. Martino Martinelli Filho Júlio César de Oliveira Carlos Eduardo Batista de Lima … Daniela Garcia Moreno Cabral Martins Cinthya Ibraim Guirao Silvana Angelina Dório Nishióka Roberto Costa Eduardo Argentino Sosa José Antonio Franchini Ramires

OBJECTIVE: To determine ventricular remodeling (VR) and the role of clinical and functional variables in patients with normal cardiac function who underwent right ventricular apical pacing (RVAP). METHODS: Among the 268 consecutive patients with standard pacemaker due to complete atrioventricular block (CAVB), those with left ventricular ejection fraction (LVEF) 53 mm on Doppler echocardiography were excluded. Ventricular remodeling was defined as echocardiographic changes documented at least six months after implantation, namely, a >10% increase in LVEDD and a > 20% decrease in LVEF. The following variables were analyzed: underlying heart disease, NYHA functional class of heart failure (HF), time of ventricular stimulation, and QRS duration. Statistical analysis included likelihood ratio test, Fisher’s exact test, and Wilcoxon rank-sum test. A p value < 0.05 was considered statistically significant. RESULTS: The study included 75 patients, mean age 70.9 ± 14, of whom 22.6% were male. Mean time between both evaluations was 80.2 months. Before implantation, mean LVEF was 72% and LVEDD was 46 mm; after implantation this values were 69.7% (p = 0.0025) and 48.5 mm (p = 0.0001), respectively. Mean QRS duration after implantation was 156 ms. Ventricular remodeling was observed only in four patients (5.3%), and no exploratory variable specified this behavior. CONCLUSION: In a long-term follow-up, patients without ventricular dysfunction who underwent RV apical pacing (RVAP) showed low VR rate, and no analyzed variable was associated with its occurrence.

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The Importance of Electrovectorcardiographic Assessment of Intraventricular Blocks and their Relationship with the Cardiac Cycle

An Unusual Manifestation of Rejection

Introduction

Correlation between Cardiomegaly on Chest X-Ray and Left Ventricular Diameter on Echocardiography in Patients with Chagas Disease

Abstract

Background

Objectives

Methods

Results

Conclusion

Painful Left Bundle Branch Block Syndrome in a Patient Referred to Electrophysiologic Study: A Case Report

Introduction

Exercise-induced left bundle branch block: prevalence and prognosis

Ventricular remodeling in right ventricular apical pacing

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