Association of Electrocardiographic Parameters with Left Ventricular Ejection Fraction in Patients with Left Bundle Branch Block and Permanent Cardiac Pacemakers
-
Muzaffar Annaev
,
Eleonora Tashkenbaeva
,
Gulnora Abdieva
,
Gulizebo Saidrasulova
,
Ismoil Tillakobilov
,
Hamida Aliakbarova
Abstract
Background: Patients with right ventricular (RV) pacing from permanent cardiac pacemakers have electrocardiographic (ECG) patterns similar to those with left bundle branch block (LBBB). Although ECG criteria for LBBB in patients with reduced left ventricular ejection fraction (LVEF) are well established, these criteria have not been clarified for patients with RV pacing.
Methods: In this retrospective observational study, between January 2016 and August 2025, 193 patients were diagnosed with LBBB, of whom 118 were included. During the same period, 475 patients with permanent cardiac pacemakers were identified, of whom 178 were eligible for the study.
Results: In the LBBB group (male/female, 55/63; mean [SD] age, 67 [12] years), 57% of patients had LV systolic dysfunction (LVEF <50%), whereas in the pacemaker group (male/female, 93/85; mean [SD] age, 72 [11] years), only 26% had an LVEF less than 50%. Mean QRS duration was longer in patients with reduced LVEF than in those with normal LV systolic function (155 [13] vs 147 [12] milliseconds, respectively; P=.034).
Conclusion: Although the ECG pattern associated with RV pacing from a permanent cardiac pacemaker resembles that of LBBB, its association with LV dysfunction differs. In patients with LBBB, longer QRS duration and the presence of q waves in leads I, aVL, V5, and V6 were associated with reduced LVEF, whereas in patients with RV pacing, a broad, notched, or slurred R wave in leads I, aVL, V5, and V6 was associated with reduced LVEF.
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2. Baldasseroni S, Opasich C, Gorini M, Lucci D, Marchionni N, Marini M, et al. Italian Network on Congestive Heart Failure Investigators. Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failure: a report from the Italian network on congestive heart failure. Am Heart J 2002; 143:398-405.
3. Wang NC, Li JZ, Adelstein EC, Althouse AD, Sharbaugh MS, Jain SK, et al. New-onset left bundle branch block-associated idiopathic nonischemic cardiomyopathy and time from diagnosis to cardiac resynchronization therapy: the NEOLITH II study. Pacing Clin Electrophysiol 2018; 41:143-54.
4. Wang NC, Singh M, Adelstein EC, Jain SK, Mendenhall GS, Shalaby AA, et al. New-onset left bundle branch block-associated idiopathic nonischemic cardiomyopathy and left ventricular ejection fraction response to guideline-directed therapies: the NEOLITH study. Heart Rhythm 2016; 13:933-42.
5. Sze E, Samad Z, Dunning A, Campbell KB, Loring Z, Atwater BD, et al. Impaired recovery of left ventricular function in patients with cardiomyopathy and left bundle branch block. J Am Coll Cardiol 2018; 71:306-17.
6. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, et al. Mode Selection Trial in Sinus-Node Dysfunction. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med 2002; 346:1854-62.
7. Birnie D, Williams K, Guo A, Mielniczuk L, Davis D, Lemery R, et al. Reasons for escalating pacemaker implants. Am J Cardiol 2006; 98:93-7.
8. Lamas GA, Pashos CL, Normand SL, McNeil B. Permanent pacemaker selection and subsequent survival in elderly Medicare pacemaker recipients. Circulation 1995; 91:1063-9.
9. Rosenbush SW, Ruggie N, Turner DA, Von Behren PL, Denes P, Fordham EW, et al. Sequence and timing of ventricular wall motion in patients with bundle branch block. Assessment by radionuclide cineangiography. Circulation 1982; 66:1113-9.
10. Bank AJ, Gage RM, Burns KV. Right ventricular pacing, mechanical dyssynchrony, and heart failure. J Cardiovasc Transl Res 2012; 5:219-31.
11. Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A, et al. American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; American College of Cardiology Foundation; Heart Rhythm Society. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009; 53:976-81.
12. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18:1440-63.
13. Shenkman HJ, Pampati V, Khandelwal AK, McKinnon J, Nori D, Kaatz S, et al. Congestive heart failure and QRS duration: establishing prognosis study. Chest 2002; 122:528-34.
14. Eriksson P, Wilhelmsen L, Rosengren A. Bundle-branch block in middle-aged men: risk of complications and death over 28 years. The Primary Prevention Study in Göteborg, Sweden. Eur Heart J 2005; 26:2300-6.
15. Park CS, Cha MJ, Choi EK, Oh S. Prognostic implication of the QRS axis and its association with myocardial scarring in patients with left bundle branch block. Korean Circ J 2017; 47:263-9.
16. Bavelaar-Croon CD, Wahba FF, Van Hecke MV, Atsma DE, Stokkel MP, Pauwels EK, et al. Perfusion and functional abnormalities outside the septal region in patients with left bundle branch block assessed with gated SPECT. Q J Nucl Med 2001; 45:108-14.
17. Hamby RI, Weissman RH, Prakash MN, Hoffman I. Left bundle branch block: a predictor of poor left ventricular function in coronary artery disease. Am Heart J 1983; 106:471-7.
18. Prinzen FW, Cheriex EC, Delhaas T, van Oosterhout MF, Arts T, Wellens HJ, et al. Asymmetric thickness of the left ventricular wall resulting from asynchronous electric activation: a study in dogs with ventricular pacing and in patients with left bundle branch block. Am Heart J 1995; 130:1045-53.
19. Murkofsky RL, Dangas G, Diamond JA, Mehta D, Schaffer A, Ambrose JA. A prolonged QRS duration on surface electrocardiogram is a specific indicator of left ventricular dysfunction. J Am Coll Cardiol 1998; 32:476-82.
20. Das MK, Cheriparambil K, Bedi A, Kassotis J, Reddy CV, Makan M, et al. Prolonged QRS duration (QRS ≥170 ms) and left axis deviation in the presence of left bundle branch block: a marker of poor left ventricular systolic function? Am Heart J 2001; 142:756-9.
21. McCullough PA, Hassan SA, Pallekonda V, Sandberg KR, Nori DB, Soman SS, et al. Bundle branch block patterns, age, renal dysfunction, and heart failure mortality. Int J Cardiol 2005; 102:303-8.
22. Deniz A, Özmen Ç, Aktaş H, Berk İG, Deveci OS, Çağlıyan ÇE, et al. Electrocardiographic markers of left ventricular systolic dysfunction in patients with left bundle branch block. Kardiol Pol 2016; 74:25-31.
23. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:1-39.
2. Baldasseroni S, Opasich C, Gorini M, Lucci D, Marchionni N, Marini M, et al. Italian Network on Congestive Heart Failure Investigators. Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failure: a report from the Italian network on congestive heart failure. Am Heart J 2002; 143:398-405.
3. Wang NC, Li JZ, Adelstein EC, Althouse AD, Sharbaugh MS, Jain SK, et al. New-onset left bundle branch block-associated idiopathic nonischemic cardiomyopathy and time from diagnosis to cardiac resynchronization therapy: the NEOLITH II study. Pacing Clin Electrophysiol 2018; 41:143-54.
4. Wang NC, Singh M, Adelstein EC, Jain SK, Mendenhall GS, Shalaby AA, et al. New-onset left bundle branch block-associated idiopathic nonischemic cardiomyopathy and left ventricular ejection fraction response to guideline-directed therapies: the NEOLITH study. Heart Rhythm 2016; 13:933-42.
5. Sze E, Samad Z, Dunning A, Campbell KB, Loring Z, Atwater BD, et al. Impaired recovery of left ventricular function in patients with cardiomyopathy and left bundle branch block. J Am Coll Cardiol 2018; 71:306-17.
6. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, et al. Mode Selection Trial in Sinus-Node Dysfunction. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med 2002; 346:1854-62.
7. Birnie D, Williams K, Guo A, Mielniczuk L, Davis D, Lemery R, et al. Reasons for escalating pacemaker implants. Am J Cardiol 2006; 98:93-7.
8. Lamas GA, Pashos CL, Normand SL, McNeil B. Permanent pacemaker selection and subsequent survival in elderly Medicare pacemaker recipients. Circulation 1995; 91:1063-9.
9. Rosenbush SW, Ruggie N, Turner DA, Von Behren PL, Denes P, Fordham EW, et al. Sequence and timing of ventricular wall motion in patients with bundle branch block. Assessment by radionuclide cineangiography. Circulation 1982; 66:1113-9.
10. Bank AJ, Gage RM, Burns KV. Right ventricular pacing, mechanical dyssynchrony, and heart failure. J Cardiovasc Transl Res 2012; 5:219-31.
11. Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A, et al. American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; American College of Cardiology Foundation; Heart Rhythm Society. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009; 53:976-81.
12. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18:1440-63.
13. Shenkman HJ, Pampati V, Khandelwal AK, McKinnon J, Nori D, Kaatz S, et al. Congestive heart failure and QRS duration: establishing prognosis study. Chest 2002; 122:528-34.
14. Eriksson P, Wilhelmsen L, Rosengren A. Bundle-branch block in middle-aged men: risk of complications and death over 28 years. The Primary Prevention Study in Göteborg, Sweden. Eur Heart J 2005; 26:2300-6.
15. Park CS, Cha MJ, Choi EK, Oh S. Prognostic implication of the QRS axis and its association with myocardial scarring in patients with left bundle branch block. Korean Circ J 2017; 47:263-9.
16. Bavelaar-Croon CD, Wahba FF, Van Hecke MV, Atsma DE, Stokkel MP, Pauwels EK, et al. Perfusion and functional abnormalities outside the septal region in patients with left bundle branch block assessed with gated SPECT. Q J Nucl Med 2001; 45:108-14.
17. Hamby RI, Weissman RH, Prakash MN, Hoffman I. Left bundle branch block: a predictor of poor left ventricular function in coronary artery disease. Am Heart J 1983; 106:471-7.
18. Prinzen FW, Cheriex EC, Delhaas T, van Oosterhout MF, Arts T, Wellens HJ, et al. Asymmetric thickness of the left ventricular wall resulting from asynchronous electric activation: a study in dogs with ventricular pacing and in patients with left bundle branch block. Am Heart J 1995; 130:1045-53.
19. Murkofsky RL, Dangas G, Diamond JA, Mehta D, Schaffer A, Ambrose JA. A prolonged QRS duration on surface electrocardiogram is a specific indicator of left ventricular dysfunction. J Am Coll Cardiol 1998; 32:476-82.
20. Das MK, Cheriparambil K, Bedi A, Kassotis J, Reddy CV, Makan M, et al. Prolonged QRS duration (QRS ≥170 ms) and left axis deviation in the presence of left bundle branch block: a marker of poor left ventricular systolic function? Am Heart J 2001; 142:756-9.
21. McCullough PA, Hassan SA, Pallekonda V, Sandberg KR, Nori DB, Soman SS, et al. Bundle branch block patterns, age, renal dysfunction, and heart failure mortality. Int J Cardiol 2005; 102:303-8.
22. Deniz A, Özmen Ç, Aktaş H, Berk İG, Deveci OS, Çağlıyan ÇE, et al. Electrocardiographic markers of left ventricular systolic dysfunction in patients with left bundle branch block. Kardiol Pol 2016; 74:25-31.
23. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:1-39.
| Files | ||
| Issue | Vol 21 No 4 (2026) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/rhythm.v21i4.23090 | |
| Keywords | ||
| Left Bundle Branch Block (LBBB) Right Ventricular (RV) Pacing Left Ventricular Ejection Fraction (LVEF) QRS Duration Electrocardiography Cardiac Pacemaker | ||
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How to Cite
1.
Annaev M, Tashkenbaeva E, Abdieva G, Saidrasulova G, Tillakobilov I, Aliakbarova H. Association of Electrocardiographic Parameters with Left Ventricular Ejection Fraction in Patients with Left Bundle Branch Block and Permanent Cardiac Pacemakers. Res Heart Yield Transl Med. 2026;21(4):274-285.
