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Hemiblocks and the fascicular system: myths and implications

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Abstract

The His bundle divides into the right bundle branch (RBB) and the more complex left bundle branch (LBB). The latter is typically represented as further dividing into anterior and posterior fascicles, and possibly an additional septal fascicle. This construct raises questions as to why conduction can be preserved in patients with “trifascicular block” and why it sometimes very difficult to ablate fascicular or papillary muscle tachycardias. The answer may be that the LBB is much more complex, variable, and interconnected and that the simple familiar constructs may have obstructed our understanding of conduction and tachycardias. Remarkably, the actual explanatory histopathology has been known for nearly half a century, spearheaded by the work of Demoulin and Kulbertus. One picture is worth a thousand words.

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References

  1. Tawara S. Das Reizleitungssystem des Saeugetierherzens: eine anatomisch-histologische Studie uber die Atrioventrikularbundel und der Purkinjeschen Faden. Jena, Germany: Verslag Gustav Fischer; 1906. p. 35–201.

    Google Scholar 

  2. Tawara S. Die topographie und histologie der bruckenfaser: ein beitrag zur lehre vonder bedeutung der Purkinjeschen faden Zantralbl Physiol. 1906; 19: 70–79.

  3. Narula OS. Longitudinal dissociation in the His bundle. Bundle branch block due to asynchronous conduction within the His bundle in man. Circulation. 1977;56(6):996–1006.

    Article  PubMed  CAS  Google Scholar 

  4. Lazzara R, Yeh BK, Samet P. Functional transverse interconnections within the His bundle and the bundle branches. Circ Research. 1973;32:509–15.

    Article  CAS  Google Scholar 

  5. Fisher JD. Bundle branch reentry tachycardia: why is the HV often longer than in sinus rhythm? The critical role of anisotropic conduction. J Interven Card Electr (JICE). 2001;5:173–6.

    Article  CAS  Google Scholar 

  6. Sarkozy A, Boussy T, Chierchia GB, Geelen P, Brugada P. An unusual form of bundle branch reentrant tachycardia. J Cardiovasc Electrophysiol. 2006;17:902–6.

    Article  PubMed  Google Scholar 

  7. Demoulin JC, Kulbertus HE. Histopathological examination of concept of left hemiblock. British Heart Journal, I972, 34, 807–814.

  8. Titus J. Normal anatomy of the human cardiac conduction system. Anesth Analg. 1973;52(4):508–14.

    Article  Google Scholar 

  9. Rosenbaum MB, Elizari MV, Lazzari I. Los Hemibloqueos. Buenos Aires: Ed. Paidos; 1967.

    Google Scholar 

  10. Dhingra RC, Denes P, Wu D, Chuquimia R, Amat-y-Leon F, Wyndham C, et al. Syncope in patients with chronic bifascicular block: significance, causative mechanisms, and clinical implications. Ann Intern Med. 1974;81(3):302–6.

    Article  PubMed  CAS  Google Scholar 

  11. Rotman M, Triebwasser JH. A clinical and follow-up study of right and left bundle branch block. Circulation. 1975;51(3):477–84.

    Article  PubMed  CAS  Google Scholar 

  12. Dhingra RC, Wyndham C, Bauernfeind R, Denes P, Wu D, Swiryn S, et al. Significance of chronic bifascicular block without apparent organic heart disease. Circulation. 1979;60:33–9.

    Article  PubMed  CAS  Google Scholar 

  13. Surawicz B. Prognosis of patients with chronic bifascicular block. Circulation. 1979;60:40–2.

    Article  PubMed  CAS  Google Scholar 

  14. Barrett PA, Peter CT, Swan HJC, et al. The frequency and prognostic significance of electrocardiographic abnormalities in clinically normal individual. Prog Cardiovasc Dis. 1981;23:299–319.

    Article  PubMed  CAS  Google Scholar 

  15. Flowers NC. Left bundle branch block: a continuously evolving concept. JACC. 1987;9(3):684–97.

    Article  PubMed  CAS  Google Scholar 

  16. Watt TB, Murao S, Pruitt RD. Left axis deviation induced experimentally in a primate heart. Am Heart J. 1965;70:381–9.

    Article  PubMed  Google Scholar 

  17. Lazzara R, Yeh BK, Samet P. Functional anatomy of the canine left bundle branch. Am J Cardiol. 1974;33:623–31.

    Article  PubMed  CAS  Google Scholar 

  18. Massing GK, James TN. Anatomical configuration of the His bundle and bundle branches in the human heart. Circulation. 1976;53:609–21.

    Article  PubMed  CAS  Google Scholar 

  19. Milliken JA. Isolated and complicated left anterior fascicular block: a review of suggested electrocardiographic criteria. J Electrocardiol. 1983;16(2):199–212.

    Article  PubMed  CAS  Google Scholar 

  20. Perez Riera AR, Uchida AH, Schapachnik E, Dubner S, Zhang L, Filho F, et al. The history of left septal fascicular block: chronological considerations of a reality yet to be universally accepted. Indian Pacing and Electrophysiology Journal. 2008;8(2):114–28.

    Google Scholar 

  21. Hoffman I, Mehta J, Hilsenrath J, Hamby RI. Anterior conduction delay: a possible cause for prominent anterior QRS forces. J Electrocardiol. 1976;9(1):15–21.

    Article  PubMed  CAS  Google Scholar 

  22. Reiffel JA, Bigger JT. Pure anterior conduction delay: a variant “fascicular” defect. J. Electrocardiology. 1978;11(4):315–9.

    Article  CAS  Google Scholar 

  23. Willems JL, Robles de Medina EO, Bernard R, Coumel P, Fisch C, Krikler D, et al. Criteria for intraventricular conduction disturbances and pre-excitation. JACC. 1985;5(6):1261–5.

    Article  PubMed  CAS  Google Scholar 

  24. Mazur A, Kusniec J, Boris SB. Bundle branch reentrant ventricular tachycardia. Indian Pacing and Electrophysiology Journal. 2005;5(2):86–95.

    PubMed  PubMed Central  Google Scholar 

  25. Kapa S, Gaba P, DeSimone CV, Asirvatham SJ. Fascicular ventricular arrhythmias: pathophysiologic mechanisms, anatomical constructs, and advances in approaches to management. Circ Arrhythm Electrophysiol. 2017;10:1–14.

    Article  Google Scholar 

  26. Al’Aref SJ, Ip JE, Markowitz SM, Liu CF, Thomas G, Frenkel D, et al. Differentiation of papillary muscle from fascicular and mitral annular ventricular arrhythmias in patients with and without structural heart disease. Circ Arrhythm Electrophysiol. 2015;8:616–24.

    Article  PubMed  Google Scholar 

  27. Crijns HJGM, Smeets JLRM, Rodriguez LM, Meijer A, Wellens HJJ. Cure of interfascicular reentrant ventricular tachycardia by ablation of the anterior fascicle of the left bundle branch. J Cardiovasc Electrophysiol. 1995;6(6):486–92.

    Article  PubMed  CAS  Google Scholar 

  28. Sadanaga T, Saeki K, Yoshimoto T, Funatsu Y, Miyazaki T. Repetitive monomorphic ventricular tachycardia of left coronary cusp origin. PACE. 1999;22:1553–6.

    Article  PubMed  CAS  Google Scholar 

  29. Kulbertus HE. The hemiblocks: a decade of study. Boehringer-Ingelheim monograph 1979. Pp 1–69; p 11, Figure 6 (by Demoulin JC).

  30. Demoulin JC, Kulbertus HE. Histopathologic correlates of left posterior fascicular block. Am J Cardiol. 1979;44(6):1083–8.

    Article  PubMed  CAS  Google Scholar 

  31. Lev M, Unger PN, Rosen KM, Bharati S. The anatomic substrate of complete left bundle branch block. Circulation. 1974;50:479–86.

    Article  PubMed  CAS  Google Scholar 

  32. Rossi L. Histopathology of conducting system in left anterior hemiblock. Br Heart J. 1976;38:1304–11.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  33. Kron IL, DiMarco JP, Nolan SP, Lerman BB. Resection of scarred papillary muscles improves outcome after surgery for ventricular. Ann Surg. 1986;203(6):685–9.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

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  1. Cardiology Division F2, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA

    John D. Fisher

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  1. John D. Fisher
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Fisher, J.D. Hemiblocks and the fascicular system: myths and implications. J Interv Card Electrophysiol 52, 281–285 (2018). https://doi.org/10.1007/s10840-018-0440-1

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  • DOI: https://doi.org/10.1007/s10840-018-0440-1

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