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Window to the Heart: The Value of a Native and Paced QRS Duration. Current Perspective and Review

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Abstract

Given the technological advances and reliance upon expensive testing for guiding therapy, it is surprising how an inexpensive, low tech electrocardiogram can provide a wealth of information pertaining to the underlying cardiovascular status of a patient. In this article we review the changes in hemodynamics, prognosis and guidance of therapeutic options associated with a prolonged QRS duration.

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References

  1. Schweitzer P, Couturier G. History of bundle branch block. ANE 2001;6(3):244; Wilson, et al. History of electrocardiography. Am Heart J 1932;7:305.

    Google Scholar 

  2. Einthoven W. Die galvanometrische Registrirung des menschlichen Electrocardiogram, zugleich eine Beurtheilung der Anwendung des Capillar-Electrometer in der physiologie. Pflug Arch Ges Physiol 1903;99:472. (English Translation in: Classics of Cardiology. Willius FA, Keys TE, Krieger RE, eds. Florida, 1961:722).

    Google Scholar 

  3. Lewis T. The spread of the excitatory process in the vertebrate heart. Part I–V. Phil Trans R Soc London, series B 1916;207:221.

    Google Scholar 

  4. Barker PS, Macleod AG, Alexander J. The excitatory process observed in the exposed human heart. Am Heart J 1930;5:720.

    Google Scholar 

  5. Wilson FN, Macleod AG, Barker PS. The order of ventricular excitation in human bundle branch block. Am Heart J 1932;7:305.

    Google Scholar 

  6. Scherf D, Boyd LJ. Clinical Electrocardiography. Mosby CV, St. Louis, 1939:57.

    Google Scholar 

  7. Hollman A. The history of bundle branch block. Medical History 1985;5(Suppl):82.

    Google Scholar 

  8. Fahy GJ, Pinski SL, Miller DP, et al. Natural history of isolated bundle branch block. Am J Cardiol. 1996;77:1185-1190.

    Google Scholar 

  9. De Bacquer D, De Backer G, Kornitzer M. Prevalences of ECG findings in large population based samples of men and women. Heart 2000;84:625.

    Google Scholar 

  10. Schneider JF, Thomas HE, Kreger BE, et al. Newly acquired left bundle branch block: the Framingham study. Ann Intern Med 1979;90:303.

    Google Scholar 

  11. Kreger BE, Anderson KM, Kannel WB. Prevalence of intraventricular block in the general population: The Framingham Study. Am Heart J 1989;117:903.

    Google Scholar 

  12. Lenegre J. Etiology and pathology of bilateral bundle branch block in relation with complete heart block. Prog Cardiovasc Dis 1964;6:409.

    Google Scholar 

  13. Lev M. Anatomic basis for atrioventricular block. Am J Med 1964;37:742.

    Google Scholar 

  14. Chou T, Knilans TK, Left Bundle branch Block. In: Chou T, Knilans TK, eds. Electrocardiography in Clinical Practice: Adult and Pediatric. 4th ed. Philidelphia: WB Saunders, 1996:75.

    Google Scholar 

  15. Schneider JF, Thomas HE, Sorlie P, et al. Comparative features of newly acquired left and right bundle branch block in the general population: The Framingham study. Am J Cardiol 1981;47:931.

    Google Scholar 

  16. Freedman RA, Alderman EL, Sheffield LT, et al. Bundle branch block in patients with chronic coronary artery diseases: Angiographic correlates and prognostic significance. J AmColl Cardiol 1987;10:73–80.

    Google Scholar 

  17. Harper JR, Harley A, Hackel DB, et al. Coronary artery disease and major conduction disturbances. Am Heart J 1969;77:411–422.

    Google Scholar 

  18. Lev M, Kinare SG, Pick A. The pathogenesis of atrioventricular block in coronary disease. Circulation 1970;42:409.

    Google Scholar 

  19. Edmands RE. An epidemiological assessment of bundle branch block. Circulation 1966;34:1081.

    Google Scholar 

  20. Eriksson P, Hansson PO, Eriksson H, et al. Bundle branch block in a general male population: the study of men born 1913. Circulation 1998;98:2494.

    Google Scholar 

  21. Fisch C. Role of electrocardiogram in identifying the patient at increased risk for sudden cardiac death. J Am Coll Cardiol 1985;5(Suppl 6):6B.

    Google Scholar 

  22. Rotman M, Triebwasser JH. A clinical and follow up study of right and left bundle branch block. Circulation 1975;51:477.

    Google Scholar 

  23. Thrainsdottir IS, Hardarson T, Thorgeirsson G, et al. The epidemiology of right bundle branch block and its association with cardiovascular morbidity—The Reykjavik Study. Eur Heart J 1993;14:1590.

    Google Scholar 

  24. McAnulty JH, Rahimtoola SH, Murphy ES, et al. A prospective study of sudden death in “high risk” bundle branch block. N Engl J Med 1978;299:209.

    Google Scholar 

  25. Hesse B, Diaz LA, Snader CE, et al. Complete bundle branch block as an independent predcator of all-cause mortality: Report of 7,073 patients referred for nuclear exercise testing. Am J Med 2001;110:253.

    Google Scholar 

  26. Morady F, Higgins J, Peters RW, et al. Electrophysiologic testing in bundle branch block and unexplained syncope. Am J Cardiol 1984;54:587.

    Google Scholar 

  27. Ezri M, Lerman BB, Marchlinski FE, et al. Electrophysiologic evaluation of syncope in patients with bifascicular block. Am Heart J 1983;106:693.

    Google Scholar 

  28. Recke SH, Esperer H-D, Eberlein U, et al. Assessment of left ventricular function from the electrocardiogram in left bundle branch block. Int J Cardiol 1989;24:297.

    Google Scholar 

  29. Das MK, Cheriparambil K, Bedi A, et al. Prolonged QRS duration (QRS ≥170 ms) and left axis deviation in the presence of left bundle branch block: Amarker of poor left ventricular systolic function? AmHeart J 2001.124;5:756.

    Google Scholar 

  30. Rahko PS, Shaver JA, Salerni R. Evaluation of mechanical events and systolic function in dilated cardiomyopathy: Comparison between patients with and without left bundle branch block. Acta Cardiologica 1988;3:179.

    Google Scholar 

  31. Grines CL, Bashore TM, Boudoulas H, et al. Functional abnormalities in isolated left bundle branch block: The effect of interventricular asynchrony. Circulation 1989;79:845.

    Google Scholar 

  32. Dillion JC, Chang S, Feigenbaum H. Echocardiographic manifestations of left bundle branch block. Circulation 1974;49:876.

    Google Scholar 

  33. Abbasi AS, Eber LM, MacAlpin RN, et al. Paradoxical septum in left bundle branch block. Circulation 1974;49:423.

    Google Scholar 

  34. McDonald IG, Feigenbaum H, Chang S. Analysis of left ventricular wall motion by reflected ultrasound: Application to assessment of myocardial function. Circulation 1972;46:14.

    Google Scholar 

  35. McDonald IG. Echocardiographic demonstration of abnormal motion of the interventricular septum in left bundle branch block. Circulation 1973;48:272.

    Google Scholar 

  36. Curtius JM, Nowitzki G, Kohler E, et al. Left bundle branch block: Inferences from ventricular septal motion in the echocardiogram concerning the left ventricular function. Z Kardiol 1983;72:635.

    Google Scholar 

  37. Shaver JA, Rahko PS, Grines CL, et al. Effects of left bundle branch block on the events of the cardiac cycle. Acta Cardiologica 1988;4:459.

    Google Scholar 

  38. Sadaniantz A, Laurent LS. Left ventricular Doppler diastolic filling patterns in patients with isolated left bundle branch block. Am J Cardiol 1998;81:643.

    Google Scholar 

  39. Dancy M, Leech G, Leatham A. Significance of complete right bundle branch block when an isolated finding. An echocardiographic study. Br Heart J 1982;48: 217.

    Google Scholar 

  40. Pickott AS, Mehta AV, Casta A, et al. Echocardiographic assessment of right bundle branch injury after repair of tetralogy of Fallot. Circulation 1981;63:174.

    Google Scholar 

  41. Wiggers CJ. The muscular reactions of the mammalian ventricle to artificial surface stimuli. Am J Physiol 1925;73:346.

    Google Scholar 

  42. Lister JW, Klotz S, Jomain SL, et al. Effect of pacemaker site on cardiac output and ventricular activation in dogs with complete heart block. Am J Cardiol 1964;14: 494.

    Google Scholar 

  43. Burkhoff D, Oikawa RY, Sagawa K. Influence of pacing site on canine left ventricular contraction. Am J Physiol 1988;254:H817.

    Google Scholar 

  44. Gilmore JP, Sarnoff SJ, Mitchell JH, et al. Synchronicity of ventricular contraction: Observations comparing hemodynamic effects of atrial and ventricular pacing. Br Heart J 1963;25:299.

    Google Scholar 

  45. Kosowsky BD, Scherlag BJ, Damoto AN. Re-evaluation of the atrial contribution to ventricular function: Study using His bundle pacing. Am J Cardiol 1968;21:518.

    Google Scholar 

  46. Finney JO. Hemodynamic alterations in left ventricular function consequent to ventricular pacing. Am J Physiol 1965; 208:275.

    Google Scholar 

  47. Dagget W, Bianco J, PowellW, et al. Relative contributions of the atrial systole-ventricular systole and of patterns of ventricular activation to ventricular function during electrical pacing of the dog heart. Circ Reas 1970;27:69.

    Google Scholar 

  48. Sheffer A, Rosenmab Y, Ben David Y, et al. Left ventricular function during physiologic pacing: Relation to rate, pacing mode and underlying myocardial disease. PACE 1987;10:315.

    Google Scholar 

  49. Leclercq C, Gras D, Le Helloco A, et al. Hemodynamic importance of preserving the normal sequence of ventricular activation in permanent cardiac pacing. Am Heart J 1995;129:1133.

    Google Scholar 

  50. Askenazi J, Alexander J, Koenigsberg D, et al. Alteration of left ventricular performance by left bundle branch block simulated with AV sequential pacing. J Am Coll Cardiol 1984;53:99.

    Google Scholar 

  51. Rosenqvist M, Isaaz K, Botvinick EH, et al. Relative importance of activation sequence compared to atrioventricular synchrony in left ventricular function. Am J Cardiol 1991; 67:148.

    Google Scholar 

  52. Lamas GA, Pashos CL, Normand SLT, et al. Permanent pacemaker selection and subsequent survival in elderly Medicare pacemaker recipients. Circulation 1995;91:1063.

    Google Scholar 

  53. Badke FR, Boinay P, Covell JW. Effects of ventricular pacing on regional ventricular performance in the dog. Am J Physiol 1980;238:H858.

    Google Scholar 

  54. Waldman LK, Covell JW. Effects of ventricular pacing on finite deformation in canine left ventricules. AmJ Physiol 1987;252:H1023.

    Google Scholar 

  55. Zile MR, Blaustein AS, Shimizu G, et al. Right ventricular pacing reduces the rate of left ventricular relaxation and filling. J Am Coll Cardiol 1987;10:702.

    Google Scholar 

  56. Heyndrickx GR, Vantrimpont PJ, Rousseau MF, et al. Effects of asynchrony on myocardial relaxation at rest and during exercise in conscious dogs. Am J Physiol 1988;254:H817.

    Google Scholar 

  57. Bedotto JB, Grayburn PA, BlackWH, et al. Alterations in left ventricular relaxation during atrioventricular pacing in humans. J AmColl Cardiol 1990;15:658.

    Google Scholar 

  58. Prinzen FW, Augustijn CH, Arts T, et al. Redistribution of myocardial fiber strain and blood flow by asynchronous activation. Am J Physiol 1990;259:H300.

    Google Scholar 

  59. Delhaas T, Arts T, Prinzen FW, et al. Regional fiber stress-fiber strain area as estimate of regional oxygen demand in the canine heart. J Physiol (London) 1994;477:481.

    Google Scholar 

  60. Baller D, Wolpers H-G, Zipfel J, et al. Comparison of the effects of right atrial, right ventricular apex and atrioventricular sequential pacing on myocardial oxygen consumption and cardiac efficiency: A laboratory investigation. PACE 1988;11:394.

    Google Scholar 

  61. Adomian GE, Beazell J. Myofibrillar disarray produced in normal hearts by electrical cardiac pacing. Am Heart J 1986;112:79.

    Google Scholar 

  62. Karpawich P, Justice C, Cavitt D, et al. Developmental sequelae of fixed-rate ventricular pacing in the immature canine heart. An electrophysiologic, hemodynamic and histopathologic evaluation. J Am Coll Cardiol 1990;119:1077.

    Google Scholar 

  63. Tse H-F, Yu C, Wong K-K, et al. Functional abnormalities in patients with permanent right ventricular pacing. J Am Coll Cardiol 2002;40:1451.

    Google Scholar 

  64. Lee MA, Dae NW, Langberger JJ, et al. Effects of longterm right ventricular apical pacing on left ventricular perfusion, innervation, function and histology. JACC 1994;24:225.

    Google Scholar 

  65. Tantengco MVT, Thomas RL, Karpawich PP. Left ventricular dysfunction after long-term right ventricular apical pacing in the young. JACC 2001;37:2093.

    Google Scholar 

  66. Jahangir A, Shen WK, Neubauer SA, et al. Relation between mode of pacing and long-term survival in the very elderly. JACC 1999;33:1208.

    Google Scholar 

  67. Jelic V, Belkic K, Djordjevic M, et al. Survival in 1,431 pacemaker patients: Prognostic factors and comparsion with the general population. PACE 1992;15:141.

    Google Scholar 

  68. Alt E, Volker R, Wirtzfeld A, et al. Survival and followup after pacemaker implantation: A comparsion of patients with sick sinus syndrome, complete heart block, and atrial fibrillation. PACE 1985;8:849.

    Google Scholar 

  69. Sweeney MO, Hellkamp AS, Greenspon AJ, et al. Baseline QRS duration >120 milliseconds and cumulative percent time ventricular paced predicts increased risk of heart failure, stroke and death in DDDR-paced patients with sick sinus syndrome in MOST (Abstract). NASPE. PACE 2002;24:690.

    Google Scholar 

  70. Lamas GA, Lee KL, Sweeney MO, et al. Ventricular pacing or dual-chamber pacing for sinus node dysfunction. New Engl J Med 2002;346:1854.

    Google Scholar 

  71. Sweeny MO, Helkamp AS, Greenspon AJ, et al. Effect of pacing mode and cumulative percent time ventricular paced on heart failure in patients with sick sinus syndrome and basseline QRS duration <120 msec in MOST (Abstract) NASPE. PACE 2002; 24:561.

    Google Scholar 

  72. The David Investigators. Dual chamber pacing or ventricular backup pacing in with an Implantable Defibrillator—The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA 2002;288(4):3115.

    Google Scholar 

  73. Victor F, Leclercq C, Mabo P, et al. Optimal right ventricular pacing site in chronically implanted patients. JACC 1999;33:311.

    Google Scholar 

  74. Blanc JJ, Etienne Y, Gilard M, et al. Evaluation of different ventricular pacing sites in patients with severe heart failure. Circulation 1997;96:3273.

    Google Scholar 

  75. Stambler BS, Ellenbogen KA, Zhang X, et al. Right ventricular outflow tract versus apical pacing (ROVA): Results of a randomized, single-blind, crossover trial in pacemaker recipients with congestive heart failure (Abstract). PACE 2002;25:557.

    Google Scholar 

  76. Gold MR. Optimization of ventricular pacing: Where should we implant the leads? J Am Coll Cardiol 1999;33:324.

    Google Scholar 

  77. Gerber TC, Nishimura RA, Holmes DR, et al. Left ventricular and biventricular pacing in congestive heart failure. Mayo Clin Proc 2001;76:803.

    Google Scholar 

  78. Xiao HB, Lee CH, Gibson DG. Effect of left bundle branch block on diastolic function in dilated cardiomyopathy. Br Heart J 1991;66:443.

    Google Scholar 

  79. Abraham WT, Fisher WG, Smith AL, et al. Cardiac Resynchronization in Chronic Heart Failure N Engl J Med 2002;346:1845.

    Google Scholar 

  80. Zardini M, Tritto M, Bargiggia G. The InSynch Italian registry: analysis of clinical outcome and considerations on the selection of candidates to left ventricular resynchronization. Eur Heart J 2002;2:J16.

    Google Scholar 

  81. Auricchio A, Stellbrink C, Sack S, et al. Chronic benefit as a result of pacing in congestive heart failure: Results of the PATH-CHF trials (Abstract). Circulation 2000;102:3352A.

    Google Scholar 

  82. Cazeau S, Leclerq C, Lavergne T, et al. Effects of multisite biventricular pacing in patients in patients with heart failure and intraventricular conduction delay. N Engl J Med 2001;344:873.

    Google Scholar 

  83. Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrythmia Devices: Summary Article. Circulation 2002:106: 2145.

    Google Scholar 

  84. Cazeau S, Ritter P, Bakduch S, et al. Four chamber pacing in dilated cardiomyopahty. PACE 1994;17:1974.

    Google Scholar 

  85. Leclercq C, Cazeau S, Le Breton H, et al. Acute hemodynamic effects of biventricular DDD pacing in patients with end stage heart failure. J Am Coll Cardiol 1998;32:1825.

    Google Scholar 

  86. Cazeau S, Ritter P, Lazarus A, et al. Multisite pacing for end stage heart failure: An early experience. PACE 1996;19:1748.

    Google Scholar 

  87. Auricchio A, Stellbrink C, Block M, et al. Effect of pacing chamber and atrioventricular delay on acute systolic function of paced patients with congestive heart failure: The pacing therapies for congestive heart failure study group. The Guidant congestive heart failure research group. Circulation 1999;99:2993.

    Google Scholar 

  88. Nelson GS, Berger RD, Fetics BJ, et al. Left ventricular or biventricular pacing improves cardiac function at diminished energy cost in patients with dilated cardiomyopathy and left bundle branch block. Circulation 2000;102:3053.

    Google Scholar 

  89. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002;346:877.

    Google Scholar 

  90. Wood S. QRS duration could single out post-MI patients who benefit from an ICD: MADIT II substudy. Heartwire.org 2002.

  91. De Teresa PA, Chamoro JL. An even more physiologic pacing: Changing the sequence of ventricular activation. Proceedings, VIIth World Symposium of Cardiac Pacing 1983; Vienna, Austria:95.

  92. Blanc JJ, Etienne Y, Gilard M, et al. Left ventricularbased pacing in patients with severe heart failure: Results of an acute hemodynamic study. Circulation 1997;96:3273.

    Google Scholar 

  93. Kass DA, Chen CH, Curry C, et al. Improved left ventricular mechanics from acute VDD pacing in patients with dilated cardiomyopathy and ventricular conduction delay. Circulation 1999;99:1567.

    Google Scholar 

  94. Nelson GS, Curry CW, Wyman BT, et al. Predicators of systolic augmentation from left ventricular preexcitation in patients with dilated cardiomyopathy and intraventricular conduction delay. Circulation 2000;101: 2703.

    Google Scholar 

  95. Kerwin WF, Botvinick EH, O'Connell JW, et al. Ventricular contraction abnormalities in dilated cardiomyopathy: Effect of biventricular pacing to correct interventicular dyssynchrony. J AmColl Cardiol 2000;35:1221.

    Google Scholar 

  96. Molhoek SG, Baxs JJ, van Erven L, et al. Effectiveness of resynchronization therapy in patients with end-stage heart failure. Am J Cardiol 2002;90:379.

    Google Scholar 

  97. Kim WY, Sogaard P, Mortenson PT, et al. Three-dimensional echocardiography docuements haemodynamic improvement by biventricular pacing in patients with severe heart failure. Heart 2001;85:514.

    Google Scholar 

  98. Bakker PF, Meijburg HW, de Vries JW, et al. Biventricular pacing in end stage heart failure improves functional capacity and left ventricular function. J Interv Cardiol Electrophysiol 2000;4:395.

    Google Scholar 

  99. Leclercq C, Cazeau S, Ritter P, et al. A pilot experience with permanent biventricular pacing to treat advanced heart failure. Am Heart J 2000;140:862.

    Google Scholar 

  100. Gras D, Mabo P, Tang T, et al. Multisite pacing as a supplemental treatment for congestive heart failure: Preliminary results of the Medtronic Inc. INSYNC study. PACE 1998;21:2249.

    Google Scholar 

  101. Linde C, Leclercq C, Rex S, et al. Long-term benefits of biventricular pacing in congestive heart failure: Results from the Multisite Stimulation in Caridomyopathy (MUSTIC) study. J AmColl Cardiol 2002;40:111.

    Google Scholar 

  102. Wilems JL, Robles de Medina EO, Bernard R, et al. Criteria for intraventricular conduction disturbances and preexcitation. J AmColl Cardiol 1985;5:1261.

    Google Scholar 

  103. Wilems JL, Robles de Medina EO, Bernard R, et al. Criteria for intraventricular conduction disturbances and preexcitation. J AmColl Cardiol 1985;5:112.

    Google Scholar 

  104. Ostrander LD, Brandt RL, Kjelsberg MO, et al. Electrocardiographic findings among the adult population of a total natural community, Tecumseh, Michagan. Circulation 1965;XXXI:888.

    Google Scholar 

  105. Baldasseroni S, Opasich C, Gorini M, et al. Left bundle branch block is associated with increased 1 year sudden and total mortality rate in 5517 outpatients with congestive heart failure from the Italian Network on Congestive Heart Failure. Am Heart J 2002;143:398.

    Google Scholar 

  106. Hardarson T, Arnason A, Eliasson GJ, et al. Left bundle branch block: prevalence, incidence, follow-up and outcome. Eur Heart J 1987;8:1075.

    Google Scholar 

  107. Ricou F, Nicod P, Gilpin E, et al. Influence of right bundle branch block on short and long term survival after inferior wall Q wall myocardial infarction. J AM Coll Cardiol 1991;67:1143.

    Google Scholar 

  108. Brilakis ES, Wright S, Kopecky SL, et al. Bundle branch block as a predictor of long term survival after acute myocardial infarction. Am J Cardiol 2001;88: 205.

    Google Scholar 

  109. Harper JR, Harley A, Hackel DB, et al. Coronary artery disease and major conduction disturbances. Am Heart J 1969;77:411–422.

    Google Scholar 

  110. Saxon LA, Kerwin WF, Cahalan MK, et al. Acute effects of intraoperative multisite ventricular pacing on left ventricular function and activation/contraction sequence in patients in patients with depressed ventricular function. J Cardiovasc Electrophysiol 1998;9:13.

    Google Scholar 

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Authors and Affiliations

  1. University of Missouri-Columbia, One Hospital Drive-MC314, Columbia, MO, 65212, USA

    Himanshu H. Shukla, Erskine A. James, John A. Schutz & Benjamin F. Lloyd

  2. Division of Cardiology, University of Missouri, Columbia, MO, USA

    Greg C. Flaker (Professor of Medicine, Director)

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  1. Himanshu H. Shukla
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  2. Erskine A. James
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  3. John A. Schutz
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Correspondence to Himanshu H. Shukla.

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Shukla, H.H., James, E.A., Schutz, J.A. et al. Window to the Heart: The Value of a Native and Paced QRS Duration. Current Perspective and Review. J Interv Card Electrophysiol 9, 333–342 (2003). https://doi.org/10.1023/A:1027487225415

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