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Eur J Cardiothorac Surg 2000;18:187-193
© 2000 Elsevier Science NL

Significance of right bundle branch block in the diagnosis of myocardial ischemia in patients undergoing coronary artery bypass grafting

^a Department of Cardiothoracic Surgery, University of Vienna, AKH Vienna, Währingergürtel 18–20, 1090 Vienna, Austria
^b Department of Cardiology, University of Innsbruck, Innsbruck, Austria
^c Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, University of Vienna, 1090 Vienna, Austria

Received 12 October 1999; received in revised form 28 February 2000; accepted 7 March 2000.

Corresponding author. Tel.: +43-1-40400-5620/5630; fax: +43-1-440-5309
e-mail: seitel{at}magnet.at

Background: Perioperative diagnosis of myocardial ischemia following cardiac surgical procedures remains a challenging problem. Particularly, the role of new conduction disturbances as markers of postoperative ischemia is still questionable. The goal of this study was to elucidate the diagnostic significance of new postoperative right bundle branch block (RBBB) for the detection of perioperative myocardial ischemia in patients undergoing elective coronary artery bypass grafting (CABG). Methods: In 169 consecutive patients, three-channel Holter monitoring and serial assessment of serum enzymes were performed for 48 h, and 12-lead ECG repeated for up to 5 days postoperatively. Postoperative events were classified as either myocardial infarction (MI), transient ischemic events (TIE) or various conduction disturbances. Results: Transient (n=9) or permanent (n=4) RBBB occurred in 13 patients (8%); 14 patients (8%) showed signs of perioperative MI and 18 patients (11%) evidence of TIE. Peak activity of creatine-kinase (CK, 561±135 vs. 316±19, P<0.05) and CK-MB (22.7±3.2 vs. 13.4±0.8, P<0.01) were higher in patients with RBBB than in patients without perioperative ischemic events. Peak CK-MB levels were significantly higher in patients with MI as compared to those with RBBB (33.4±7.6 vs. 22.7±3.2, P<0.05). Patients with TIE had similar perioperative enzyme levels as patients with no events. Conclusion: It is concluded that the combined assessment of repeated 12-lead ECG, continuous Holter monitoring and enzyme analysis allows a reliable diagnosis of perioperative myocardial ischemia and conduction disturbances. The occurrence of new RBBB following elective CABG is indicative of perioperative myocardial necrosis and thus serves as a valuable tool for the diagnosis of new, perioperative ischemic events.

Key Words: Right bundle branch block • Coronary artery bypass grafting • Myocardial ischemia • Enzyme analysis • Holter monitoring

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