Patients who present with LBBB may have a congenital heart defect or prior cardiac surgery. The medical history should include symptoms like exercise tolerance, presence of fatigue, dyspnea, syncope, orthopnea and falls. The duration and intensity of symptoms should be recorded.

Physical exam may be unremarkable in some patients with LBBB, but auscultation may reveal a diminished or absent first heart sound and/or reversed splitting of the 2nd heart sound. Patients with heart failure may present with the following features:

• Elevated jugular venous pressure
• Rales and crackles
• Pedal edema
• Presence of S3 and/or mitral regurgitation

• Exertional Dyspnea

  A 61-year-old man was referred to our hospital with exertional dyspnea. Electrocardiography showed atrial fibrillation (AF) with a heart rate of 116 bpm and left bundle branch block (LBBB). [ncbi.nlm.nih.gov]

• Heart Disease

  There are many causes of left bundle branch block (LBBB) that include heart disease that developed at birth, open heart surgery procedures and following a heart attack. [symptoma.com]

  The left bundle branch block itself can cause the heart to work less efficiently in people who have certain types of heart disease. Left Bundle Branch Block and Underlying Heart Disease Left bundle branch block mainly affects older adults. [verywell.com]

  Before taking ranolazine, on the background of conventional treatment of coronary heart disease, the patient developed stable angina and persistent left bundle branch block, atrial fibrillation. [ncbi.nlm.nih.gov]

• Irritability

  The proposed explanation and pathogenetic mechanism of this clinical manifestation is transdiaphragmatic epicardial irritation secondary to acute pancreatitis. [omicsonline.org]

  Health Hormones Horseback Riding Human Learning Hydration Hydrotherapy Hygiene Hyperglycemia Hypertension Hypertrophy Hysterectomy Ice Hockey Impingement Syndrome Incontinence Inflammation Injury Prevention Insulin Integrated Training Interval Training Irritable [ptonthenet.com]

  Secure or long-term venous access that is not available using other sites IV infusion of fluids and drugs for patients in cardiac arrest IV infusion of concentrated or irritating fluids IV infusion of high flows or large fluid volumes beyond what is possible [msdmanuals.com]

In a patient with LBBB, blood work is not essential as it is often noncontributory. However, in symptomatic patients it is important to order cardiac biomarkers to ensure that the patient has not suffered a myocardial infarction. Levels of creatine kinase, troponin and LDH should be serially ordered in symptomatic patients. If the cause of LBBB is due to an infection or an inflammatory process, ESR or CRP levels should be ordered. While not specific for myocarditis, they do help in assessing the effects of treatment. Other blood work will depend on the suspected cause of the LBBB.

Routine blood work that is done includes:

• Complete blood count
• Electrolyte levels
• Renal and liver function
• Coagulation profile
• Blood cultures if endocarditis is suspected
• Lipid profile

Additional studies

• Serial ECGs are required in patients with LBBB. There are criteria that have been established to determine the presence of a LBBB on the ECG. If amyocardial infarction is suspected in the presence of LBBB, one needs to use Sgarbossa’s scoring criteria [7].
• A chest X-ray is done to determine presence of heart failure.
• Some patients in whom the diagnosis is not clear may require 24 hour holter monitoring to determine presence of any other co-existing arrhythmia [8].
• An echocardiogram is usually done to assess heart and valve function. The method can also detect presence of vegetations on the leaflet.

• Left Axis Deviation

  Any significant frontal axis deviation implies that the spatial axis is also deviated. [radcliffecardiology.com]

  Left bundle branch block is usually associated with normal or left axis deviation. Rarely the ECG shows a LBBB with changing QRS morphology and changing axis deviation. [ncbi.nlm.nih.gov]

  ECGs showing the LBBB Note the following ECG features of the LBBB: -Downwardly deflected QRS -Delayed R wave progression -Wide QRS -Poor or delayed R wave progression (no positive initial deflections in leads V2-V4) -Left axis deviation [ecgsforems.blogspot.com]

• Wide QRS Complex

  However, in some patients, LBBB may vary with heart rate, and during episodes of AF in LBBB, aberrant ventricular conduction, or wide QRS complex tachycardia (Ashman beats) can occur. [ncbi.nlm.nih.gov]

  These altered electrical forces produce a wide QRS complex (greater than 0.12 seconds in duration) with an abnormal morphology. [meds.queensu.ca]

  A 12-lead ECG in the ER showed sinus tachycardia at 118 beats/min, wide QRS complexes, peaked T waves and left bundle branch block-like pattern. The initial basic metabolic panel revealed a serum potassium level of 8.8 mEq/L. [cardiologyres.org]

  With left bundle branch block, the wide QRS complex appears upright in certain leads, and downward in others. [verywell.com]

  Henneman et al. [ 32 ] studied 75 patients with heart failure, depressed left ventricular function, and wide QRS complex using gated SPECT and two-dimensional echocardiography, including tissue Doppler imaging (TDI). [link.springer.com]

• Torsades De Pointes

  During hospitalization she developed torsade de pointes and complete AVB with increased QTc. The echocardiogram showed images compatible with LVNC. [ncbi.nlm.nih.gov]

• Left Anterior Fascicular Block

  There are also partial blocks of the left bundle branch: "left anterior fascicular block" (LAFB) and a "left posterior fascicular block" (LPFB). This refers to the bifurcation of the left bundle branch. [en.wikipedia.org]

  Type II blocks nearly always have a wide QRS due to the underlying bundle branch pathology. You may see RBBB, LBBB, or RBBB with left anterior fascicular block (hemiblock). Very rarely, the combination might include left posterior hemiblock. [ecgguru.com]

  Related Topics Left bundle branch block LBBB Right Bundle Branch Block RBBB Left anterior fascicular block LAFB Left posterior fascicular block LPFB Interventricular Conduction Delay IVCD Bifascicular block Trifascicular block Complete Heart block CHB [lifeinthefastlane.com]

  Some premature P waves are conducted with left anterior fascicular block (LAFB) while some others are conducted with left bundle branch block (LBBB) morphology. Click here for a more detailed ECG ECG 6. [metealpaslan.com]

• Bifascicular Block

  The criteria to diagnose bifascicular block, BBB, hemiblock, and A-V blocks were based on the recommendations of the Criteria Committee of the New York Heart Association [14] : Bifascicular block: right BBB with left anterior or left posterior fascicular [anesthesiology.pubs.asahq.org]

  Bifascicular blocks require no direct treatment unless intermittent 2nd- or 3rd-degree AV block is present. True trifascicular blocks require immediate, then permanent pacing. [merckmanuals.com]

  Bifascicular block If the left anterior fascicle (or left posterior fascicle but this is much less common) and the right bundle are blocked you will see both right bundle branch block and left axis deviation, this is known as bifascicular block. [oxfordmedicaleducation.com]

  Related Topics Left bundle branch block LBBB Right Bundle Branch Block RBBB Left anterior fascicular block LAFB Left posterior fascicular block LPFB Interventricular Conduction Delay IVCD Bifascicular block Trifascicular block Complete Heart block CHB [lifeinthefastlane.com]

All patients who have been diagnosed with LBBB need a thorough workup of their heart. It is important to treat the underlying cause if found. There is no medical therapy to treat LBBB. In all asymptomatic patients the treatment is an annual ECG.

For patients who have syncope or symptoms of heart failure, a dual chamber cardiac pacemaker is required. While resynchronization therapy may help improve symptoms, survival is not always improved. The improvement in patients is variable and not predictable [9]. Pacemakers can be inserted by the cardiologist or cardiac surgeon under local anesthesia. In most cases, progression to a complete heart block is rare.

Left bundle branch block does not progress to a complete heart block in most cases. The overall prognosis of LBBB depends on coexisting cardiac disease. In patients with heart failure, biventricular pacing can improve symptoms and morbidity. In general, the higher the cardiac morbidity, the poorer is the prognosis in the presence of LBBB. Patients who develop LBB after open heart surgery procedures generally do not have a higher morbidity as long as the primary disorder has been surgically corrected.

LBBB has several causes which include the following:

• Congenital abnormalities of the conduction system (eg. Lev’s disease or Lenegre-lev syndrome where there is heart block due to calcification and fibrosis of the electrical pathways).
• Certain congenital disorders like Noonan syndrome and Down syndrome are also associated with heart defects like endocardial cushion defects, complete AV canal or large ventricular septal defects. Infants with tricuspid atresia, single ventricle, or double outlet ventricle are also at high risk for developing LBBB.
• Congenital anatomical malformations that primarily those that involve the left ventricular outflow tract (eg. subvalvar resection of subvalvar aortic tissue) and surgical repair of VSD.
• Post open heart surgery procedures such as surgery on the septum, left ventricular outflow tract, myomectomy, aortic valve replacement or procedures to enlarge the aortic annulus.
• Percutaneous technique of septal ablation with alcohol for treatment of idiopathic hypertrophic cardiomyopathy.
• Percutaneous catheter closure of muscular septal defect.
• May also be seen in patients with left ventricular hypertrophy, viral or bacterial (eg. diphtheria) myocarditis, cardiomyopathy and following myocardial infarction [3] [4].
• Endocarditis of the aortic valve and rheumatic fever that involves the aortic valve [5] [6].
• Prenatal exposure to HIV can sometimes present with LBBB.
• Wolff-Parkinson-White syndrome
• Left ventricular hypertrophy from prolonged hypertension.

In children LBBB is usually associated with congenial heart disease and is quite rare in normal healthy children. In adults, LBBB may appear after a variety of open heart surgery procedures on the left ventricular outflow tract such as after aortic valve replacement, surgery on the septum, or aortic annulus. The exact number of people with LBBB is not known but the numbers are not miniscule. Because many patients remain asymptomatic, they never come to medical attention. The disorder can occur in people of all ages and in all races.

Left bundle branch block develops when there is interruption of the electrical impulse in the heart. The conduction from the sinus node is normal until it reaches the bundle of His-Purkinje tissues. At this point the electrical conduction may be delayed or absent. There can be either a complete LBBB or an incomplete left bundle branch block known as a hemiblock. The damage to the electrical conduction may be a result of structural defects in the heart since birth (eg. endocardial cushion defects) or they may be caused during open heart surgery on the left ventricular outflow tract.

Prevention of LBBB is not possible in most cases. For children born with heart defects, it is important to follow up closely with a cardiologist to ensure that the disease is not progressing. If the child becomes symptomatic, pacing may be required. Adults who undergo open heart surgery and develop LBBB generally do not show symptoms as long as surgery corrected the primary disorder. However, symptomatic adults who develop heart failure may need a permanent pacemaker. For patients who developed an LBBB after a myocardial infarction, change in lifestyle is important. This means eating healthy, discontinuing smoking, regular exercise and remaining compliant with medications. Levels of cholesterol and blood sugar should be controlled to prevent progression of atherosclerotic heart disease.

Left bundle branch block (LBBB) is a conduction abnormality seen on the ECG when the regular sequence of electrical impulse is altered in the His-Purkinje fibers. In the majority of cases, this conduction abnormality is seen in people with some type of underling heart disease. However, it must be noted that LBBB may also be seen in people with no symptoms and in the presence of any structural defect in the heart. When LBBB is identified on the ECG it often makes the diagnosis of a myocardial infarction difficult. In addition, this conduction abnormality also interferes with the ECG analysis in patients who undergo exercise testing. Patients who have a low ejection fraction and develop LBBB, generally tend to develop dyssynchronous ventricular beats that eventually results in congestive heart failure. It is important to realize that LBBB may not always cause symptoms but it is not a benign disorder [1] [2].

There are many causes of left bundle branch block (LBBB) that include heart disease that developed at birth, open heart surgery procedures and following a heart attack. Patients should be told that LBBB rarely progresses to a complete heart block or cause sudden death and to watch out for other symptoms of heart disease like shortness of breath, swelling of the legs, chest pain or fatigue. They should be encouraged to have annual visits for a physical checkup and undergo a 12 lead ECG if they develop chest pain or dizziness. All symptomatic patients should be told to have more frequent visits with their cardiologist. Patients should be told that there may be a need for a pacemaker if the symptoms of heart failure do not respond to medications. Patients with LBBB need instructions on what types of activities they can carry out. Patients who are symptomatic or have a tendency to develop arrhythmias need to limit themselves from intense physical activity. Those patients without symptoms can perform most daily living activities.

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