Limitations of ECG algorithms in paced right bundle branch block with prior myocardial infarction

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Complete atrioventricular block with preexisting right bundle branch block and inferolateral Q-wave myocardial infarction (n=1). Intervention: Right ventricular apical and outflow tract pacing assessed with Coman-Trohman and Okmen ECG algorithms. Primary outcome: Confirmation of right ventricular lead placement and resolution of paced right bundle branch block pattern.

Q: What does this research mean for the field?

Preexisting inferolateral Q-wave myocardial infarction causes false-positive left ventricular pacing indications on ECG algorithms during right ventricular apical pacing, whereas right ventricular outflow tract pacing restores the expected left bundle branch block morphology. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Daniel Antwi‐Amoabeng; T. David Gbadebo

doi:10.1016/j.hrcr.2021.07.007

July 29, 2021HeartRhythm Case ReportsOpen Access

Limitations of ECG algorithms in paced right bundle branch block with prior myocardial infarction

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Key result

Preexisting inferolateral Q-wave infarction caused false-positive LV pacing indications on ECG algorithms during RV apical pacing, whereas RV outflow tract pacing restored the expected LBBB pattern.

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Why the study?

Paced RBBB during RV pacing raises concern for inadvertent LV pacing, and while ECG-based algorithms have been developed to confirm proper lead placement, prior myocardial infarction can introduce pitfalls that affect their diagnostic accuracy.

Key Points

To evaluate the diagnostic accuracy and potential pitfalls of surface electrocardiogram algorithms for verifying true right ventricular pacemaker lead placement in a patient with preexisting right bundle branch block and prior myocardial infarction.
Assessed a 55-year-old man with complete atrioventricular block, preexisting right bundle branch block (RBBB), and prior inferolateral myocardial infarction who underwent dual-chamber pacemaker implantation.
Evaluated post-implantation surface ECGs using the Coman-Trohman and Okmen algorithms alongside 2-view chest radiographs to verify pacing lead position.
Analyzed ECG morphology changes following lead extraction and reimplantation in the right ventricular outflow tract (RVOT) after a pocket infection.
Despite 2-view chest radiography confirming true right ventricular apical lead placement, both Coman-Trohman and Okmen algorithms incorrectly suggested left ventricular pacing because the frontal axis was not between -30 and -90 degrees and precordial transition failed to occur by V3 due to infarct-related poor R-wave progression.
Reimplantation of the ventricular lead into the right ventricular outflow tract eliminated the paced RBBB pattern, converted the axis from left axis deviation to right axis deviation, and produced the expected left bundle branch block pattern in lead V1.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 male patient, aged 55 years, with complete atrioventricular block, preexisting right bundle branch block, and prior inferolateral Q-wave myocardial infarction requiring an emergent dual-chamber pacemaker.

I

Intervention

Dual-chamber pacemaker implantation with right ventricular (RV) apical lead placement, later extracted due to pocket infection and re-implanted in the right ventricular outflow tract (RVOT); application of Coman-Trohman and Okmen ECG algorithms to assess lead placement.

O

Outcome

Diagnostic accuracy of ECG algorithms (Coman-Trohman and Okmen criteria) in confirming proper RV lead placement and resolution of the paced RBBB pattern into an expected left bundle branch block (LBBB) pattern.surrogate

In patients with preexisting RBBB and inferolateral myocardial infarction, standard ECG algorithms can falsely indicate inadvertent LV pacing during true RV apical pacing, making chest radiography essential for confirmation and the RV outflow tract a preferred pacing site.

Limitations

Single-patient case report
Preexisting Q-wave inferolateral infarcts and poor precordial R-wave progression limit the diagnostic accuracy of Coman-Trohman and Okmen ECG algorithms
Preexisting Q-wave infarcts and poor precordial R-wave progression limit the performance of Coman-Trohman and Okmen ECG algorithms at detecting proper RV lead placement

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Implication

ECG algorithms warrant caution in post-inferolateral MI patients during RV apical pacing; case report leaves open generalizability and optimal site selection.

Abstract

In patients with normal baseline cardiac conduction, a left bundle branch block (LBBB) pattern is expected with right ventricle (RV) pacing.1 Paced right bundle branch block (RBBB) raises several concerns; inadvertent intraventricular left ventricle (LV) pacing is the most serious. Often, a 2-view chest radiograph is useful in assessing proper lead placement. Electrocardiogram (ECG) acquisition maneuvers and ECG-based algorithms have been developed to provide important confirmatory information.2–4 While ECGs allow for rapid identification of uncomplicated RV pacing, clinicians must be aware of the pitfalls that can affect the diagnostic accuracy of an ECG-based approach in the context of prior myocardial infarction.

Discussion

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Cite This Study

Antwi‐Amoabeng et al. (2021) conducted a case report in Complete atrioventricular block with preexisting right bundle branch block and inferolateral Q-wave myocardial infarction (n=1). Right ventricular apical and outflow tract pacing assessed with Coman-Trohman and Okmen ECG algorithms was evaluated on Confirmation of right ventricular lead placement and resolution of paced right bundle branch block pattern. Preexisting inferolateral Q-wave infarction caused false-positive LV pacing indications on ECG algorithms during RV apical pacing, whereas RV outflow tract pacing restored the expected LBBB pattern.

synapsesocial.com/papers/6a9412f0714eeec8661d5b52 https://doi.org/10.1016/j.hrcr.2021.07.007

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Limitations of ECG algorithms in paced right bundle branch block with prior myocardial infarction

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Limitations of ECG algorithms in paced right bundle branch block with prior myocardial infarction

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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