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Trifascicular Block—A Consequence of Pulmonary Angiography
ELECTROCARDIOGRAM OF THE MONTH
Trifascicular Block-A Consequence of Pulmonary Angiography* Alberto Benchimol, M.D., and Kenneth B. Desser, M.D.
Selective coronary arteriography can produce significant axis shifts of the mean QRS of the electrocardiogram in the frontal plane. I •2 These abnormalities and others, usually transient, have attributed to possible ischemic or toxic effects produced by the bolus of dye utilized. I •3 Different degrees of both left anterior hemiblock and left posterior hemiblock probably are the mechanisms which produced these axis shifts. This case report describes the development of transient trifascicular block as a consequence of pulmonary angiography.
tigue, dyspnea and chest pain. On physical examination the pertinent findings were: blood pressure 120/64 mm Hg; pulse 78/min; a grade IV/VI systolic ejection murmur and a grade III/VI blowing decrescendo arterial diastolic murmur at the aortic and tricuspid areas. The clinical impression was aortic stenosis and insufficiency, probably rheumatic in origin. On admission an electrocardiogram showed nonspecific ST segment and T wave changes and small Q waves in leads I, aVL and V2 through V6 (Fig 1). The patient was subjected to diagnostic right and left heart catheterization including selective coronary arteriography and the findings suggested the diagnosis of predominant aortic stenosis with mild insufficiency. The coronary arteriogram was normal. Right heart functions were normal. Pulmonary angiography was performed with a No.7 bipolar Zucker catheter using 30 ml of 75 percent diatrizoate (Hypaque). During injection of the contrast medium into the pulmonary artery, an oscillographic monitoring lead II of the electrocardiogram revealed the appearance of a prolonged P-R interval and an initial r followed by a broad S wave. A standard 12 lead scalar electrocardiogram showed changes compatible with block of
CASE REPORT
A 51-year-old woman was referred for diagnostic cardiac catheterization. The patient had experienced progressive fa°From the Instihtte for Cardiovascular Diseases, Good Samaritan Hospital, Phoenix, Arizona. Supported in part by Nichols' Memorial Fund.
FIGURE 1. Admission electrocardiogram reveals sinus rhythm, normal QRS axis, small Q waves in leads I, aVL, V2 to V6, compatible with either old anteroseptal infarction or septal hypertrophy. Nonspecific ST segment and T wave changes are also present.
391
392
BENCHIMOL AND DESSER '"
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FIGURE 2. Electrocardiogram taken approximately two houTS after cardiac catheterization reveals sinus rhythm, P-R interval 0.21 second (seen best in lead aVR ), abnormal left axis deviation (QRS vector at -50 degrees ), complete right bundle branch block, small Q waves in leads I, aVL, V2 to V6. the anterior-superior division of the left bundle branch, complete right bundle branch block, and partial block of the post~rior-inferior left bundle fascicle (Fig 2). These findings were confirmed on the Frank vectorcardiogram. The patient was observed during the next 24 hours and an electrocardiogram taken at the end of that period had returned to precatheterization findings consistent with the pattern of left ventricular hypertrophy and "strain" (Fig 3).
FIGURE 3. Electrocardiogram taken 24 hours after pulmonary angiography reveals sinus rhythm, normal QRS, left ventricular hypertrophy with a "strain" pattern, and small Q waves in leads I, aVL. v:! to V6. With respect to QRS morphology, this tracing is essentially identical to the tracing taken on admi.'lsion.
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DISCUSSION
The concept of a trifascicular bundle branch system is commonly accepted. 4 Furthermore, individual fascicular blocks, and combinations thereof, have been proposed. :; The electrocardiographic changes reported herein, occurring during pulmonary angiography, are attributed to trifascicular
.
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CHEST, VOL. 60, NO.4, OCTOBER 1971
TRIFASCICULAR BLOCK
block. Specifically, the abnormal left axis deviation with broad S waves in leads I, II, III, aVL, V3 to V6, tall broad R' in lead aVR; rSR' in lead V1; all on the basis of left anterior hemiblock and right bundle branch block. The prolonged P-R interval is suggestive of delay in conduction through the posterior-inferior division of the left bundle. The mechanism producing these blocks is speculative, but as in coronary arteriography, toxic and/ or ischemic influences of the contrast medium may have affected the conduction system. Reflex coronary artery spasm during pulmonary artery injection, acute dilatation of the pulmonary artery, and mechanical effects of the intracardiac catheters may have played a role. Other unusual, as yet unexplained conduction abnormalities on an apparent electro-mechanical basis have been reported. 6 Although artificial pacing was not needed in our case, the importance of utilizing a bipolar catheter during routine right and left heart investigation is
CHEST, VOL. 60, NO.4, OCTOBER 1971
393 evident. The addition of complete left posterior hemiblock could have led to complete heart block in our patient. REFERENCES
1 Maytin 0, Castillo C, Castellanos A Jr: The genesis of QRS changes produced by selective coronary arteriography. Circulation 41 :247, 1970 2 Fernandez F, Scebat L, Lenegre J: Electrocardiographic study of left intraventricular hemiblock in man during selective coronary arteriography. Amer J Cardiol26:1, 1970 3 Benchimol A, McNally EM: Hemodynamic and electrocardiographic effects of selective coronary angiography in man. New Eng J Moo 274:1217,1966 4 Rosenbaum MB, Elizari MY, Lazzari JO: Los Hemibloqueos. Buenos Aires, Ed. Paidos, 1968 5 Rosenbaum MB, Elizari MY, Lazzari JO, et al: Intraventricular trifascicular blocks. Review of the literature and classification. Amer Heart J 78:450, 1969 6 Goldberg E: WOOenslcy phenomena in the human heart. Amer Heart J 78:840,1969
Reprint requests: Dr. Benchimol, 1033 East McDowell Road, Phoenix 85006
Trifascicular Block-A Consequence of Pulmonary Angiography* Alberto Benchimol, M.D., and Kenneth B. Desser, M.D.
Selective coronary arteriography can produce significant axis shifts of the mean QRS of the electrocardiogram in the frontal plane. I •2 These abnormalities and others, usually transient, have attributed to possible ischemic or toxic effects produced by the bolus of dye utilized. I •3 Different degrees of both left anterior hemiblock and left posterior hemiblock probably are the mechanisms which produced these axis shifts. This case report describes the development of transient trifascicular block as a consequence of pulmonary angiography.
tigue, dyspnea and chest pain. On physical examination the pertinent findings were: blood pressure 120/64 mm Hg; pulse 78/min; a grade IV/VI systolic ejection murmur and a grade III/VI blowing decrescendo arterial diastolic murmur at the aortic and tricuspid areas. The clinical impression was aortic stenosis and insufficiency, probably rheumatic in origin. On admission an electrocardiogram showed nonspecific ST segment and T wave changes and small Q waves in leads I, aVL and V2 through V6 (Fig 1). The patient was subjected to diagnostic right and left heart catheterization including selective coronary arteriography and the findings suggested the diagnosis of predominant aortic stenosis with mild insufficiency. The coronary arteriogram was normal. Right heart functions were normal. Pulmonary angiography was performed with a No.7 bipolar Zucker catheter using 30 ml of 75 percent diatrizoate (Hypaque). During injection of the contrast medium into the pulmonary artery, an oscillographic monitoring lead II of the electrocardiogram revealed the appearance of a prolonged P-R interval and an initial r followed by a broad S wave. A standard 12 lead scalar electrocardiogram showed changes compatible with block of
CASE REPORT
A 51-year-old woman was referred for diagnostic cardiac catheterization. The patient had experienced progressive fa°From the Instihtte for Cardiovascular Diseases, Good Samaritan Hospital, Phoenix, Arizona. Supported in part by Nichols' Memorial Fund.
FIGURE 1. Admission electrocardiogram reveals sinus rhythm, normal QRS axis, small Q waves in leads I, aVL, V2 to V6, compatible with either old anteroseptal infarction or septal hypertrophy. Nonspecific ST segment and T wave changes are also present.
391
392
BENCHIMOL AND DESSER '"
.
. .
f:p;pp:pp++:+.m:.'~
",t-+++=H",.,j..·. c;;P;;ftq .....
.. I
: i
:;:;;:;:
...'I.;:i .• ';':.;;
...... ::".: ". ~;j~ ~~:; :~;
::J.: :l'
I
FIGURE 2. Electrocardiogram taken approximately two houTS after cardiac catheterization reveals sinus rhythm, P-R interval 0.21 second (seen best in lead aVR ), abnormal left axis deviation (QRS vector at -50 degrees ), complete right bundle branch block, small Q waves in leads I, aVL, V2 to V6. the anterior-superior division of the left bundle branch, complete right bundle branch block, and partial block of the post~rior-inferior left bundle fascicle (Fig 2). These findings were confirmed on the Frank vectorcardiogram. The patient was observed during the next 24 hours and an electrocardiogram taken at the end of that period had returned to precatheterization findings consistent with the pattern of left ventricular hypertrophy and "strain" (Fig 3).
FIGURE 3. Electrocardiogram taken 24 hours after pulmonary angiography reveals sinus rhythm, normal QRS, left ventricular hypertrophy with a "strain" pattern, and small Q waves in leads I, aVL. v:! to V6. With respect to QRS morphology, this tracing is essentially identical to the tracing taken on admi.'lsion.
•...•. :. '•.,. ...
... ::.]
........::·.:.. 1
. .•... _. . . . . " .• _
DISCUSSION
The concept of a trifascicular bundle branch system is commonly accepted. 4 Furthermore, individual fascicular blocks, and combinations thereof, have been proposed. :; The electrocardiographic changes reported herein, occurring during pulmonary angiography, are attributed to trifascicular
.
.:" . .
..
•
. .. ..
. : :: ~:.
..
::."". ..:j
'.:::: •.::1. I.: I' "'1 ! I ! !
..,\ .::
:::•...... :,,:::::::::;;,::.i:::I";':::~:J
..:,:.::::;;:::.:::::.;;:....
. . . . • .···:1·
! .\'.
;:H
CHEST, VOL. 60, NO.4, OCTOBER 1971
TRIFASCICULAR BLOCK
block. Specifically, the abnormal left axis deviation with broad S waves in leads I, II, III, aVL, V3 to V6, tall broad R' in lead aVR; rSR' in lead V1; all on the basis of left anterior hemiblock and right bundle branch block. The prolonged P-R interval is suggestive of delay in conduction through the posterior-inferior division of the left bundle. The mechanism producing these blocks is speculative, but as in coronary arteriography, toxic and/ or ischemic influences of the contrast medium may have affected the conduction system. Reflex coronary artery spasm during pulmonary artery injection, acute dilatation of the pulmonary artery, and mechanical effects of the intracardiac catheters may have played a role. Other unusual, as yet unexplained conduction abnormalities on an apparent electro-mechanical basis have been reported. 6 Although artificial pacing was not needed in our case, the importance of utilizing a bipolar catheter during routine right and left heart investigation is
CHEST, VOL. 60, NO.4, OCTOBER 1971
393 evident. The addition of complete left posterior hemiblock could have led to complete heart block in our patient. REFERENCES
1 Maytin 0, Castillo C, Castellanos A Jr: The genesis of QRS changes produced by selective coronary arteriography. Circulation 41 :247, 1970 2 Fernandez F, Scebat L, Lenegre J: Electrocardiographic study of left intraventricular hemiblock in man during selective coronary arteriography. Amer J Cardiol26:1, 1970 3 Benchimol A, McNally EM: Hemodynamic and electrocardiographic effects of selective coronary angiography in man. New Eng J Moo 274:1217,1966 4 Rosenbaum MB, Elizari MY, Lazzari JO: Los Hemibloqueos. Buenos Aires, Ed. Paidos, 1968 5 Rosenbaum MB, Elizari MY, Lazzari JO, et al: Intraventricular trifascicular blocks. Review of the literature and classification. Amer Heart J 78:450, 1969 6 Goldberg E: WOOenslcy phenomena in the human heart. Amer Heart J 78:840,1969
Reprint requests: Dr. Benchimol, 1033 East McDowell Road, Phoenix 85006