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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

Rainald Seitelbergera, Thomas Wilda, Nermin Serbecica, Severin Schwarzacherb, Meinhard Plonera, Andrea Lassniggc, Bruno Podessera

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


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 
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


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 References
 
Ventricular conduction disturbances following coronary artery bypass surgery (CABG) are a common phenomenon with a prevalence of up to 43% [1–4]. However, their significance as a diagnostic and prognostic indicator of perioperative myocardial ischemia and clinical outcome remains controversial. Although some studies demonstrated that the postoperative occurrence of new left bundle branch block (LBBB) may have an unfavorable impact on survival and long-term clinical prognosis [1,2], other investigations were unable to confirm these data [3,5,6]. Accordingly, there is no conclusive answer to the question, whether or not the occurrence of transient or permanent new right bundle branch block (RBBB) is related to considerable perioperative myocardial ischemia and/or associated with worsened clinical outcome [2–4,6,7].

Caspi et al. reported that 62% of patients with new postoperative LBBB and only 20% with RBBB showed elevated creatine kinase (CK)-MB levels of more than 5% of total serum CK and abnormal time–release curves [1]. These data, however, were not directly compared with those of patients with either perioperative myocardial infarction (MI) or an uneventful postoperative course. In contrast, Hake et al. demonstrated impaired left ventricular function and elevated enzyme levels in patients with new, permanent RBBB following CABG [7]. In patients with coronary artery disease, the occurrence of even transient intraventricular conduction disturbances including RBBB is a reliable indicator of myocardial ischemia during exercise testing [8].

The goal of the present study was to investigate the significance of transient or permanent RBBB in the diagnosis of perioperative myocardial ischemia. One hundred and seventy-three consecutive patients undergoing CABG were monitored by means of 12-lead ECG and Holter monitoring, and serial assessment of serum enzyme levels. Data of patients with new RBBB were then compared with those having either an uneventful postoperative course, or demonstrating electrocardiographic signs of MI or transient myocardial ischemia (TIE).


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 References
 
The study was performed on 173 consecutive patients, who underwent CABG. Patients with preoperative LBBB or RBBB, atrioventricular block, previous coronary bypass grafting, recent MI (<3 weeks), additional operative procedures, or need of rethoracotomy because of excessive postoperative bleeding were excluded from the study. Early mortality (defined as death occurring during hospitalization or within 30 days after operation) was 2.3% (four patients). Since none of these patients had signs of a new LBBB or RBBB or met the follow-up criteria, they were excluded from the study, leaving 169 patients for analysis.

Patients were premedicated with midazolam and received standard general anesthesia with midazolam, etomidate, fentanyl and pancuronium. Controlled mechanical ventilation with oxygen/air was provided to achieve normoventilation. The cardiopulmonary bypass circuit consisted of a hollow-fiber oxygenator (Bard HF 5701, C.R. Bard Inc., Havorhill, MA) primed with Ringer's lactate 2000 ml, mannitol 20 g, heparin 8000 IU (Immuno, Vienna, Austria) and aprotinin 1 000 000 IU (Trasylol Bayer, Leverkusen, Germany). Flow during CPB was maintained at 2.5 l/min per m2 and mild hypothermia (34°C) was employed. Myocardial protection consisted of cold, intermittent blood cardioplegia administered ante- (induction) and retrogradely. Body rewarming began during completion of the last distal anastomose. A partial occlusion clamp was used for the proximal anastomoses. For continuous monitoring of perioperative arterial and pulmonary artery pressure, a radial artery cannula and a Swan–Ganz catheter (percutaneously into the pulmonary artery via the jugular vein) were inserted preoperatively.

2.1. Holter monitoring and electrocardiographic recordings
Two methods were used to assess perioperative electrocardiographic changes.

(1) Continuous three-channel Holter monitoring was performed using Marquette Holter Recorders (Series 8500). The evaluation was performed on a semiautomatic basis using a Marquette Laser Holter XP device. Monitoring began 2 h after opening of the aortic cross-clamp and lasted for 48 h. The electrodes were placed so that channels 1–3 approximated ECG-leads V2, V5 and aVF, respectively.

(2) Twelve-lead ECG recordings were performed shortly before and 2, 4, 6, 8, 12, 16, 20, 24, 36 and 48 h after operation, as well as every day until the sixth postoperative day.

All Holter tapes and ECG-recordings were reviewed by the same investigator. Five different forms of perioperative myocardial events were defined by the combined analysis of electrocardiographic and Holter recordings using the following criteria.

2.1.1. Transient ischemic event (TIE)
Horizontal or downsloping ST-segment depression of >=1 mm and lasting at least 1 min measured 60–80 ms from the J-point in at least one Holter channel with no signs of evolving MI.

2.1.2. Myocardial infarction
(a) Persistent typical ST-segment elevation of >=2 mm, measured 60–80 ms from the J-point in at least one Holter channel and development of a new Q wave (>0.04 s in duration and more than one quarter of the following R wave in amplitude) in the corresponding 12-lead ECG after 6 days and/or during the 48 h observation period after surgery.

(b) Persistent negative coronary T wave of >3 mm in 12-lead ECG during the 48-h postoperative observation period and/or 6 days after surgery without occurrence of a new Q wave.

2.1.3. Right bundle branch block
New occurrence of minimum QRS duration of >=0.12 s with typical RSR configuration in V1 and/or in V2 and with deep, late S waves in I, V5 and/or V6 for more than 48 h duration and at discharge-ECG (permanent), and less than 48 h in duration (transient).

2.1.4. Left anterior hemiblock (LAHB)
New occurrence of a frontal axis>-30° with a small Q in I and aVL, small R waves in II, III and aVF, and S waves in V1–V6.

2.1.5. Left axis deviation
New occurrence of a frontal axis>-30° with a small Q in I and aVL, small R waves in II, III, and aVF, and no S waves in V1–V6.

2.1.6. Left bundle branch block
New occurrence of minimum QRS duration of >0.12 s with an absent Q wave, a notched or slurred R in I, V5 and/or V6, and wide right precordial S waves.

2.2. Biochemical analysis
Creatine kinase (CK, units/l, normal values: 0–70) and the MB-isoenzyme of CK (CK-MB, units/l, normal values: 0–10) were assessed immediately before surgery and 4, 8, 12, 16, 20, 24, 36 and 48 h after aortic cross-clamp time using enzymatic fluorometric methods.

2.3. Statistical analysis
All data are presented as mean±standard deviation (SD). An analysis of variance (ANOVA) was used to compare CK and CK-MB values. Since those values demonstrated a non-normal distribution, adequate transformations were performed: peak values were assessed in a logarithmic fashion and compared. (significance level: P<0.05). In addition, the time corrected area under the curve (AUC) for CK and CK-MB data was assessed in a logarithmic fashion and compared (significance level: P<0.05). Pairwise comparisons were performed using the correction of Tukey (significance level: P<0.05). Spot-checks of peak values were carried out using empiric quantiles and summarized using box-and-whiskers plots.

For statistical data analysis, the SPSS 9.0 (SPSS Inc.) statistical package was used.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 References
 
Clinical and anamnestic characteristics of all patients included in the study are presented in Table 1. Table 2 shows the incidence of perioperative MI and transient ischemia as well as of new postoperative transient or permanent RBBB. In patients with perioperative MI, 12 developed a new Q wave and two had a persistent, negative coronary T wave. None of the patients investigated showed electrocardiographic signs of new LBBB. Two of the 13 patients with new RBBB (one transient, one permanent) had an additional LAHB and two had additional first-degree atrioventricular block. Six patients with RBBB also showed ECG-signs of left axis deviation but none of the patients had evidence of concomitant MI.


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  		Table 1. Preoperative data

 

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  		Table 2. Incidence of perioperative events

 
Table 3 compares surgical data of all patients with regard to the incidence of perioperative events such as RBBB, TIE or MI. No relevant differences with regard to aortic cross-clamp time, incidence of endarterectomy and total number of distal anastomoses was detected between the groups of patients with RBBB and MI as compared to those without events.


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  		Table 3. Surgical dataa

 
There was no obvious difference with regard to catecholamine support during the postoperative course between patients with or without perioperative ischemic events (seven out of 27 patients with either RBBB or MI, 23 out of 142 patients with either TIE or no event). Peak values of postoperative CK and CK-MB for patients with either an uneventful postoperative course or electrocardiographic signs of RBBB, TIE or MI are presented in Figs. 1 and 2 (box-and-whiskers plots). Since no obvious difference in peak CK and CK-MB values and the respective time curves were observed between patients with either transient or permanent postoperative RBBB, or between those with or without additional left axis deviation or left anterior hemiblock, the enzyme data of these subgroups of patients were not analyzed separately.



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  		Fig. 1. Box-and-whiskers plot of peak serum CK levels for all groups. NE, patients with no event; TIE, patients with transient ischemic events; RBBB, patients with right bundle branch block; MI, patients with myocardial infarction. Data are given as percentiles. The central box shows the data between the quartiles (25- and 75-percentiles), with the median represented by a bold line.

 


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  		Fig. 2. Box-and-whiskers plot of peak serum CK-MB levels for all groups. NE, patients with no event; TIE, patients with transient ischemic events; RBBB, patients with right bundle branch block; MI, patients with myocardial infarction. Data are given as percentiles. The central box shows the data between the quartiles (25- and 75-percentiles), with the median represented by a bold line.

 
Patients with either MI or RBBB developed significantly higher peak CK and CK-MB values as compared to those with an uneventful postoperative course. Whereas the CK-peak values between patients with MI and RBBB did not reach statistical difference due to the high variability of CK values in the RBBB group, all other groups demonstrated significant differences between each other (P<0.001; Tukey corrected for paired data: P<0.001). However, the analysis of CK-MB-peak values revealed significant differences between all four groups (overall: P<0.001; Tukey-corrected P<0.001 for all paired comparisons).

The time courses of CK-MB values for all groups until 48 h after the operation are depicted in Fig. 3 . Due to the inadequate efficiency of analyzing single values at respective time points, the AUC for each group was evaluated. The AUC was proportional to the mean values over the 48-h observation period. According to this analysis, all four groups were significantly different among each other (overall: P<0.001; Tukey-corrected P<0.001 for all paired comparisons).



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  		Fig. 3. Bar graph of serum CK-MB levels before surgery (pOp) and for 48 h after opening of the aortic cross-clamp. MB, MB-isoenzyme of creatine kinase; NE, patients with no event; TIE, patients with transient ischemic events; RBBB, patients with right bundle branch block; MI, patients with myocardial infarction. Data are given as mean±SD. Data were analyzed by calculating the AUC for each group. All groups were significantly different among each other (overall: P<0.001; Tukey-corrected for all paired comparisons: P<0.001).

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
References
 
Coronary artery bypass grafting has become a routine operative procedure designed to eliminate the various symptoms of angina pectoris, to decrease the incidence of MI and to extend long-term survival in patients with coronary artery disease. Myocardial preservation during aortic cross-clamping has substantially improved and operative mortality has reached a remarkably low level. However, the incidence of early postoperative myocardial ischemia of various degrees remains a rather common complication with a variance of 2–20% for the prevalence of new MI [9–11] and up to 40% for TIE [11,12]. Due to the various methodological problems in the diagnosis of ischemia during the early postoperative period, the true incidence of postoperative ischemia may be even higher.

Apart from diagnostic methods with high sensitivity and specificity such as myocardial uptake of technetium-99m pyrophosphate on a scintigram or transesophageal echocardiography for detection of regional functional changes, which cannot be used for routine follow-up, the analysis of ECG and enzyme release constitute the standard methods for the diagnosis of postoperative myocardial ischemia. In most reports, new MI (defined as the development of a new Q wave with or without preceding ST segment elevation) remains the gold standard for defining the postoperative complication of myocardial ischemia. However, various reports also emphasized the possible diagnostic significance of the new occurrence of conduction disturbances such as RBBB or LBBB [1–3,7].

Whereas the significance of LBBB as an indicator of perioperative myocardial ischemia is widely accepted [1,7], the diagnostic significance of the occurrence of new RBBB after coronary bypass grafting remains controversial [2–7]. In nonsurgical patients the occurrence of transient or permanent RBBB at rest or during exercise is usually associated with small vessel disease concomitant to fibrodegenerative changes, severe proximal left anterior descending coronary artery disease or induced by right ventricular involvement in inferior wall left ventricular MI [8,13–15]. Especially in combination with MI, RBBB is also associated with poorer prognosis and increased in-hospital and 1-year postdischarge mortality [14–16].

Following coronary bypass grafting, increased CK-MB activities, impaired postoperative regional myocardial function, greater demand for catecholamines or complicated postoperative course have primarily been observed in patients who developed a new permanent RBBB [2,7].

The results of the present study clearly show that new transient and/or permanent RBBB are associated with markedly higher perioperative CK-MB levels than in patients with an uneventful postoperative course. Consequently, the occurrence of new RBBB must be linked to myocardial cell necrosis and appears indicative of perioperative myocardial ischemia. However, since perioperative CK-MB values of patients with ECG-proven transmural MI were higher than in patients with new RBBB, the extent of the ischemic damage of myocardial cells is certainly smaller in these patients and does not reach the average extent of cell necrosis induced by a transmural MI.

The significance of a certain conduction disturbance as an indicator of myocardial ischemia must be based on a reliable, ischemia-specific diagnostic parameter in order to compare its diagnostic value with other, widely acknowledged, indicators of perioperative myocardial ischemia. In this study, myocardial ischemia was defined either by the occurrence of new MI or of a TIE. Perioperative time courses and peak values of CK and CK-MB as indicators of the extent of myocardial cell necrosis were then used to compare patients with new MI or TIE to those with conduction disturbances.

The diagnosis of MI was based on the combined analysis of repeated ECG and continuous Holter recordings, and required the existence of a persistent ST segment elevation of >2 mm prior to the development of a new Q wave in the corresponding lead. In addition, a negative coronary T wave of >3 mm persisting throughout the 6-day observation period was also classified as MI [11]. Whereas this definition of MI is widely accepted, conflicting reports have been published about the diagnostic accuracy of serum enzymes for the detection of significant myocardial ischemia, such as MI.

Although CK-MB release seems to be a reliable biochemical indicator for perioperative MI, the lack of a generally accepted cutoff value (defined as peak activity or total quantity) and the interpatient variability of CK-MB levels compromise its diagnostic sensitivity [17,18]. Nevertheless, in this study, both CK as well as CK-MB levels were markedly higher in patients with perioperative MI assessed by the combined analysis of ECG and Holter monitoring recordings than in patients with either an uneventful postoperative course or with TIE only. Given the assumption that serum enzyme levels reflect, at least to a certain degree, the amount of damaged myocardial tissue [17], the significantly higher CK and CK-MB values of patients with RBBB as compared to those with no event or only TIE indicate that RBBB does reflect the occurrence of myocardial ischemia in patients undergoing coronary bypass grafting.

In contrast to other reports, we did not detect any relevant differences in postoperative enzyme release patterns between patients with transient or permanent RBBB [2,7]. However, since the latest follow-up ECG in this study was only 6 days after surgery, our definition of permanent RBBB as any RBBB lasting at least 48 h during the postoperative period may have overestimated the true number of patients with permanent RBBB.

Several reasons have been implicated to cause postoperative conduction disturbances such as a higher incidence of preoperative MI, a higher number of diseased coronary vessels and applied bypass grafts, longer aortic cross-clamp time and the use of cold potassium cardioplegia [1,3,5,19–22]. In the present study, however, we were unable to identify risk factors for the perioperative occurrence of RBBB. Whereas the relatively low number of patients in our study with new RBBB did not allow a stepwise analysis of variance of preoperative clinical data predictive of perioperative myocardial ischemia, intraoperative data such as aortic clamp time, incidence of coronary endarterectomy and number of grafts were comparable between patients with and without ischemia or conduction disturbances. However, it has to be mentioned that the overall low incidence of new RBBB and/or new MI in conjunction with the relatively low maximum CK and CK-MB values in those patients is in line with the assumption that the use of ante/retrograde blood cardioplegia may provide more effective intraoperative myocardial protection than crystalloid cardioplegic solutions [4,19,21,22]. This would also explain the fact that we did not observe relevant perioperative complications such as hemodynamic instability in patients with perioperative RBBB or even MI.

In conclusion, this study on patients undergoing coronary bypass grafting demonstrates that the perioperative occurrence of new transient or permanent RBBB is indicative of myocardial ischemia and is associated with myocardial cell necrosis. The extent of myocardial damage associated with new RBBB, however, appears less in comparison to patients with new MI and is not associated with significant hemodynamic complications during the early postoperative period.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 

  1. Caspi Y., Safadi T., Ammar R., Elamy A., Fishman N.H., Merin G. The significance of bundle branch block in the immediate postoperative electrocardiograms of patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg 1987;93:442-446.[Abstract]
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