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Cardiovascular magnetic resonance features of mechanical dyssynchrony in patients with left bundle branch block

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Abstract

Patients with left bundle branch block (LBBB) can exhibit mechanical dyssynchrony which may contribute to heart failure; such patients may benefit from cardiac resynchronization treatment (CRT). While cardiac magnetic resonance imaging (CMR) has become a common part of heart failure work-up, CMR features of mechanical dyssynchrony in patients with LBBB have not been well characterized. This study aims to investigate the potential of CMR to characterize mechanical features of LBBB. CMR examinations from 43 patients with LBBB on their electrocardiogram, but without significant focal structural abnormalities, and from 43 age- and gender-matched normal controls were retrospectively reviewed. The following mechanical features of LBBB were evaluated: septal flash (SF), apical rocking (AR), delayed aortic valve opening measured relative to both end-diastole (AVOED) and pulmonic valve opening (AVOPVO), delayed left-ventricular (LV) free-wall contraction, and curvatures of the septum and LV free-wall. Septal displacement curves were also generated, using feature-tracking techniques. The echocardiographic findings of LBBB were also reviewed in those subjects for whom they were available. LBBB was significantly associated with the presence of SF and AR; within the LBBB group, 79 % had SF and 65 % had AR. Delayed AVOED, AVOPVO, and delayed LV free-wall contraction were significantly associated with LBBB. AVOED and AVOPVO positively correlated with QRS duration and negatively correlated with ejection fraction. Hearts with electrocardiographic evidence of LBBB showed lower septal-to-LV free-wall curvature ratios at end-diastole compared to normal controls. CMR can be used to identify and evaluate mechanical dyssynchrony in patients with LBBB. None of the normal controls showed the mechanical features associated with LBBB. Moreover, not all patients with LBBB showed the same degree of mechanical dyssynchrony, which could have implications for CRT.

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Acknowledgments

We thank James S. Babb, PhD (Associate Professor, New York University School of Medicine), who provided statistical advice. We also thank Alan Vainrib, MD, who provided help with the assessment of dyssynchrony findings in selected echocardiographic examinations.

Author information

Correspondence to Leon Axel.

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The authors declare that they have no conflict of interest.

Electronic supplementary material

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Online Resource 1 a Short axis SSFP cine demonstrating Septal Flash, early inward motion of the septum with lateral wall stretching, followed by outward motion of the septum when the lateral wall begins to contract. (AVI 9573 KB)

Online Resource 1 a Short axis SSFP cine demonstrating Septal Flash, early inward motion of the septum with lateral wall stretching, followed by outward motion of the septum when the lateral wall begins to contract. (AVI 9573 KB)

Online Resource 1 b Short axis SSFP cine in a normal control for comparison. (AVI 7369 KB)

Online Resource 1 b Short axis SSFP cine in a normal control for comparison. (AVI 7369 KB)

Online Resource 2 a 4 Chamber SSFP cine demonstrating both Septal Flash and Apical Rocking. In apical rocking, there is a rocking motion of the LV apex perpendicular to the LV long axis. The apex is first pulled rightwards, then leftward with the onset of lateral wall contraction. (AVI 3131 KB)

Online Resource 2 a 4 Chamber SSFP cine demonstrating both Septal Flash and Apical Rocking. In apical rocking, there is a rocking motion of the LV apex perpendicular to the LV long axis. The apex is first pulled rightwards, then leftward with the onset of lateral wall contraction. (AVI 3131 KB)

Online Resource 2 b 4 Chamber SSFP cine in a normal control, for comparison. (AVI 3036 KB)

Online Resource 2 b 4 Chamber SSFP cine in a normal control, for comparison. (AVI 3036 KB)

Online Resource 3 a Phase contrast imaging demonstrating delayed opening of the aortic valve relative to the pulmonic valve in a patient with LBBB. With delayed LV ejection in LBBB, flow is first identified in the main pulmonary artery, followed by flow in the aorta. (AVI 6858 KB)

Online Resource 3 a Phase contrast imaging demonstrating delayed opening of the aortic valve relative to the pulmonic valve in a patient with LBBB. With delayed LV ejection in LBBB, flow is first identified in the main pulmonary artery, followed by flow in the aorta. (AVI 6858 KB)

Online Resource 3 b Phase contrast imaging in a normal control demonstrating flow occurring simultaneously in the main pulmonary artery and the aorta. (AVI 6445 KB)

Online Resource 3 b Phase contrast imaging in a normal control demonstrating flow occurring simultaneously in the main pulmonary artery and the aorta. (AVI 6445 KB)

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Revah, G., Wu, V., Huntjens, P.R. et al. Cardiovascular magnetic resonance features of mechanical dyssynchrony in patients with left bundle branch block. Int J Cardiovasc Imaging 32, 1427–1438 (2016) doi:10.1007/s10554-016-0925-x

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Keywords

  • Left bundle branch block
  • Mechanical dyssynchrony
  • Cardiovascular magnetic resonance
  • Septal flash
  • Apical rocking