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24. Narula OS, Samet P: Right bundle branch block with normal,
left or right axis deviation: analysis by His bundle recordings.
Am J Med 51: 432, 1971
25. Haft JI, Kranz PD: Intraventricular conduction intervals dur-
ing orthograde conduction in patients with complete heart
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26. Rifkin RD, Hood WB Jr: Bayesian analysis of electrocardio-
graphic exercise testing. .N Engl J Med 297: 681, 1977
27. Peters RV, Scheinman MM, Modin G, O'Young J, Somelofski
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Framingham study. Ann Intern Med 92: 37, 1980
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cases. Am J Cardiol 44: 1396, 1979

Left Fascicular Blocks During Right-heart

Catheterization Using the Swan-Ganz Catheter
AGUSTIN CASTELLANOS, M.D., ANTONIO V. RAMIREZ, M.D.,
ALVARO MAYORGA-CORTES, M.D., KYRIACOS PEFKAROS, M.D.,
JOHN J. ROZANSKI, M.D., CHARLES SPRUNG, M.D., AND ROBERT J. MYERBURG, M.D.
Downloaded from http://ahajournals.org by on February 13, 2023

SUMMARY During insertion of Swan-Ganz catheters, mechanical right bundle branch block occurred in
association with left posterior fascicular block in two patients and with left anterior fascicular block in two.
None of the four patients had acute myocardial infarction or acute (spontaneous or iatrogenic) pulmonary dis.
ease. In two cases, electrophysiologic studies demonstrated the coexistence of intra- and infra-Hisian conduc-
tion delays and blocks. Although the right bundle branch block may have resulted from injury to the central or
peripheral right branch, the left fascicular blocks could not be explained by direct trauma to these left-sided
structures. Our findings support the recent clinical and experimental reports that show that, left fascicular
block (as well as right bundle branch block) may be due to lesions involving the His bundle; presumably
because of longitudinal dissociation of this structure affecting the transverse interconnections. In one patient,
2: 1 intra-Hisian block may have coexisted with bradycardia-dependent (phase 4) right bundle branch block.
More studies are required to determine the implications of catheter-induced conduction disturbances in other
clinical settings, such as acute myocardial infarction.

RARELY, complications result from the use of the
Swan-Ganz catheters. Recent communications have
reported distal migration of catheters with pulmo-
nary artery injury or pulmonary infarction.1-8 Rhythm
disorders and conduction disturbances, such as ven-
tricular ectopic beats and traumatic right bundle
branch block (RBBB), have also been noted."-" Be-
cause the catheter is confined to the right-heart cavi-
ties, axis shifts characteristic of left anterior fascic-
From the Division of Cardiology, Department of Medicine,
University of Miami School of Medicine, Miami, Florida.
Supported in part by grant 5 ROI HL 18769-06, NHLBI, NIH.
Address for correspondence: Agustin Castellanos, M.D., Division
of Cardiology (D-39), University of Miami School of Medicine,
P.O. Box 016960, Miami, Florida 33101.
Received October 6, 1980; revision accepted March 3, 1981.
Circulation 64, No. 6, 1981.
ular block (LAFB) and left posterior fascicular block
(LPFB) would not be expected to develop coincident
with traumatic RBBB. However, these unusual asso-
ciations can occur and are discussed in this report.
We also examine possible electrophysiologic mecha-
nisms.
Materials and Methods
Table 1 lists clinical data for four patients who, dur-
ing insertion of a Swan-Ganz catheter, developed
RBBB with LPFB (cases 1 and 2) or with LAFB
(cases 3 and 4). Although one patient had old antero-
septal (and possibly inferior) myocardial infarctions,
none had acute myocardial infarction by clinical,
enzymatic or electrocardiographic findings, or acute
pulmonary disease by clinical or x-ray findings or lung
 1272 CIRCULATION VOL 64, No 6, DECEMBER 1981

scans). One patient had congestive cardiomyopathy
and three had systemic arterial hypertension with car-
diomegaly and congestive heart failure (hypertensive
cardiovascular disease). Hemodynamic monitoring
was performed to evaluate the treatment of congestive
heart failure, acute hypertensive crisis or volume de-
pletion.
Triple-lumen, #7F, balloon-tipped, flow-directed
thermodilution catheters (Edwards Laboratories)
were introduced through an antecubital or internal
jugular vein. After entering the appropriate vein, the
distal lumen was connected to the pressure monitor-
ing system. After balloon inflation,.the catheter was
advanced to the pulmonary artery under fluoroscopic
control to obtain pulmonary artery pressures (table 1).
Although an electrocardiographic lead was visually
monitored on the oscilloscope screen during the entire
procedure, continuous tracings were obtained in only
two patients. However, in all cases, a complete 12-lead
ECG was recorded at the end of the procedure.
His bundle studies were performed.in two patients,
using techniques previously reported."
Results
Right Bundle Branch Block and Pulmonary Artery Pressures
None of the patients had RBBB before insertion of
the Swan-Ganz catheter. This conduction disturbance
persisted for 6-l 1 hours (table 1).
The initial hemodynamic measurements showed
that cases 1-3 had elevated pulmonary artery end-
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pearance of the RBBB was preceded by (or coexisted
with) right ventricular ectopic beats. The RBBB was
initially bradycardia-dependent, and then became
rate-independent.
In patients 1 and 2, the amount of rightward shift of
the electrical axis from the control value was 1100 and
1200, (table 1). The magnitude of this shift and the
resulting right-axis deviation (which could not be at-
tributed to acute lung disease) were in keeping with
the diagnosis of LPFB.10
In case 2, the control ECG (fig. 1A) showed a left
atrial abnormality and left ventricular hypertrophy
with an electrical axis of +30° and a QRS duration of
85 msec. The RBBB pattern that appeared after inser-
tion (fig. 1B and fig. 2, top) was associated with right-
axis deviation (+1400) and a QRS duration of 100
msec. In this patient, the traumatically induced intra-
ventricular conduction disturbances had disappeared
11 hours after insertion of the catheter (fig. 2B).
RBBB with LAFB
Case 3 had a control ECG showing old antero-
septal (and probably inferior) myocardial infarctions
with an electrical axis of -15° (fig. 3A). The RBBB
pattern, which appeared while the Swan-Ganz cath-
eter was introduced, occurred without significant
changes in rate. It was associated with a shift of the
electrical axis to approximately -100°, consistent
with the diagnosis of LAFB1' (fig. 3B). Total dis-
appearance (6 hours later) of the RBBB was followed
by a gradual shift to the electrical axis toward control

diastolic pressures. Measurements performed 4 hours values: -45° at 6 hours and - 150 (as in the control
after starting a drip infusion of nitroprusside revealed ECG) at 10 hours.
a decrease of the pulmonary artery end-diastolic In case 4 (figs. 4 and 5), traumatic RBBB coexisted
pressure to acceptable levels (table 1). This response not only with LAFB, but also with 2:1 atrioventric-
occurred when the RBBB was still present. Case 4 had ular (AV) block (fig. 4B). These conduction distur-
hypovolemia with an initial low pulmonary artery bances had disappeared 9 hours later (fig. 4C).
end-diastolic pressure.
His Bundle Recordings
RBBB with LPFB Intracardiac electrophysiologic studies, performed
In case 1, contin-uous electrocardiographic record- in cases 1 and 4, showed normal AH intervals.
ings were obtained throughout the procedure. Ap- However, both had infranodal conduction distur-
TABLE 1. Clinical, Electrocardiographic and Hemodynamic Information
EA (direc-
EAEAtion tion and
an Duration
Duration Pulmonary artery pressures
Age Clinical Previous EA (during magnitude of RBBB Pulmonary_artery_pressures
Pt (years) diagnosis MI (control) RBBB) of shift) (hours) Systolic End-diastolic Mean
1 47 HCVD No 00 +1200 R (1200) 6 0 hours* 28 22 25
CHF 4 hourst 22 13 17
2 57 HCVD No +300 +1400 R (1100) 11 0 hours* 26 20 23
CHF 4 hourst 23 12 17
3 52 AHD- ASW -150 -100° L (800) 10 0 hours* 30 24 27
HCVD IW 4 hourst 26 15 20
4 62 CM No +750 _400 L (1050) 9 0 hours* 16 5 10
HV 4 hourst 20 16 20
Abbreviations: MI = myocardial infarction; EA = electrical axis; RBBB = right bundle branch block; R = right; L = left;
HCVD= hypertensive cardiovascular disease; CHF = congestive heart disease; AHD = atherosclerotic heart disease; ASW =
anteroseptal wall; IW = inferior wall; CM = congestive cardiomyopathy; HV = hypovolemia.
*Initial measurements.
¶Measurements obtained 4 hours later.
 FASCICULAR BLOCKS WITH SWAN-GANZ/Castellanos e't atl27
FIGURE 1. Case 2. (A) Control 12-lead ECG. (B) The rhythm strip (lead I) recorded after introduction of
the Swan-Ganz catheter shows a significant change in QRS morphology.
bances. In case 1, the HV was prolonged (65 msec). In
case 4 (fig. 5), the intracavitary recordings (corre-
sponding to the rhythm strip in fig. 4B) showed that
the 2:1 AV block was due to 2:1 intra-Hisian block.
Whereas the first, third and fifth atrial deflections
(after having traversed the AV node) were abnormally
delayed within the His bundle (HH' of 60 msec), the
second, fourth and sixth were blocked between the
proximal His bundle site and the distal site, because H
was not followed by H'. The conducted QRS complex-
es had a RBBB-LAFB pattern (figs. 4B and 5).
Discussion
Downloaded from http://ahajournals.org by on February 13, 2023
RBBB After Insertion of the Swan-Ganz Catheter
It has been assumed that the right ventricular endo-
...
.....
.....
---
B .
FIGURE 2. Case 2. Twelve-lead ECGs.
after introduction of Swan-Ganz catheter.
bances 11 hours later.
1273
cardial structures are protected from significant irrita-
tion by the catheter tip by the inflated balloon. Yet, in-
duction of right ventricular ectopic beats and transient
RBBB indicates that some degree of trauma does oc-
cur. Luck and Engel,51 who observed transient RBBB
in three of 38 patients (7.9%), suggested that the cathe-
ter tip is not always the cause of mechanical irritation;
RBBB may also result from a rigid catheter loop fixed
at the site of venous introduction and at the site of
pulmonary artery occlusion. Other authors have also
described the development of a new RBBB during
bedside pulmonary artery catheterization using
balloon-tipped catheters.8, "'i1
Moreover, Aguilar et al.,'3 Rosen et al.'4 and Jacob-
son and Scheinman'8 reported that paroxysmal AV
(HV) block could occur during recording of His bun-
....... ........
........
..........
V -p~~~~~~~~~~~~~~~.
.
........ ............
....... ..... .. .... . . . . .
.... ......
(A) Left posterior fascicular block with right bundle branch block
(B) Disappearance of the intraventricular conduction distur-
 ._vs-,^te;I4.815-L:24I1;HSs-e+t9E,wIz;F5
1274 CIRCULATION VOL 64, No 6, DECEMBER 1981

I I : $0. . . . ..: IIa*V, R 0i 1 5 6 aVFoV, A;..;. . . Vi *g..s

di
f1a<11
E~ ~ ~ ~~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~.
ii 41F%¶JIN..14.Jjji
.dV,;tj .ttvAs ....li,b-,,M
.......
....;t
?_
.sti S't|X-
i o S |
Li ;...

..
..A
........
-;
1. -S....
ll.. :.:.-. i...:
....---
--- ---- 1--- - :. 1. ... |t < oL

1J-

FIGURE 3. Case 3. Twelve-lead ECGs before (A), immediately after (B), and 8 hours after (C) introduction
of Swan-Ganz catheter.

dle electrograms in patients with complete left bundle For example, case 1 of Jacobson and Scheinmanl6 and
branch block. This could have been due to traumatic our case 4 had periods of second-degree intra-Hisian
RBBB. block with RBBB in the conducted beats. Although
Catheter-induced RBBB mechanical injury to the corresponding structures can-
Coexisting with Intra-Hisian Block not be excluded, the RBBB could have been a pre-
existing (latent) nontraumatic bradycardia-related
When the association of RBBB and intra-Hisian (phase 4) conduction disturbance, exposed only when
block results from mechanical lesions affecting these the time of arrival of excitation at the right bundle
two separate structures, either both lesions are trau- branch was made late enough by the traumatic sec-
Downloaded from http://ahajournals.org by on February 13, 2023

matic, or one is traumatic and the other spontaneous. ond-degree intra-Hisian block.

l 11 111 aVR aVL aVF V1 Vs V6

u
_ ,.
,, ..
_
-4+e
*
4+ -+ -l | f _
--=
L--'-l'''
-tM
-- m 1
[4t-t^--S
--5-*
;l j5gltj;
tatts44
. __ 4
* s

X - :-1:--2 --B _-jS S--' X

A1 ---. - -g;
w_ .
_
_ _ _

_ ..
__

..
_ _ _
X + + E 14 4 lE-F

A2 leade a 11

Ie a d I1 l

wggPf X ~~~~~~~~~~~~~~~lead
11
FIGURE 4. Case 4. Recordings before (Al and A2), immediately after (B), and 9 hours after (C) intro-
duction of Swan-Ganz catheter. Strip B shows 2:1 atrioventricular (AV) block and right bundle branch
block with left anterior fascicular block (fig. 5).
 FASCICULAR BLOCKS WITH SWAN-GANZ/Castellanos et al. 1275

p p p p p p
I
11

v] .H II
m mi HI rIIi H1p9II1 II
9H5
HBE _yi
111".
11
. ro.
I At
A H' A A H A A H' A
A H :100
-

H H: 60
-

H-V 50
FIGURE 5. Case 4. His bundle recordings corresponding to the strip shown in figure 4B. Whereas the first,
third and fifth P waves are conducted with an intra-Hisian delay (HH' interval) of 60 msec, the second,
fourth and sixth are blocked below the site from which the proximal His bundle deflection (H) was recorded.
Intervals between time markings equal 1000 msec. HBE = His bundle electrographic lead; A = atrial deflec-
tion recorded in the HBE lead.

Left Fascicular Blocks Related to
Right-sided Catheterization
Production of LAFB and LPFB by catheters
located in the right-sided cavities cannot, of course, be
due to direct trauma to left-sided structures. Yet,
these unusual findings may be explained by assuming
Downloaded from http://ahajournals.org by on February 13, 2023
existing left bundle branch block. Although we present
only four patients, there could be a subgroup of
patients, with or without latent disease of the ven-
tricular specialized conduction system, in whom me-
chanical trauma can produce left fascicular blocks or
bundle branch blocks.

that left fascicular blocks, as well as RBBB, can be
produced by lesions limited to the His bundle.'>28
Longitudinal dissociation of conduction within the
His bundle must be present for this to occur, but there
is disagreement as to the mechanism, especially in
regard to the role played by the transverse intercon-
nections between the longitudinal strands.
However, the LAFB in case 4 could have been a
preexisting (latent) bradycardia-dependent (phase 4)
conduction disturbance exposed by the second-degree
intra-Hisian block. Furthermore, Fabregas et al.18 and
Scherlag et al.25 as well as the clinical observations of
Narula20 suggest that the bundle branch block and left
fascicular block produced by intra-Hisian lesions can
also be rate-related. Fabregas et al.l8 showed that bra-
dycardia-dependent (phase 4) block may sometimes
occur. They showed that, after the His bundle was in-
jured, 1:1 conduction to the left fascicles coexisted
with 2:1 conduction to the right bundle branch. The
increased duration of the interval between the stimulus
artifact and the beginning of phase 0 depolarization of
the action potential of the right bundle branch was at-
tributed to the slow conduction resulting from an in-
crease in the slope of diastolic depolarization.
Clinical Implications
RBBB produced by the Swan-Ganz catheters has
been clinically significant only in patients with pre-
However, prospective studies are needed. These re-
quire continuous electrocardiographic monitoring
(ideally using at least two leads) during the proce-
dure. Also needed is the establishment of a priori
assumptions regarding the number of consecutive
beats showing a given conduction disturbance that are
required to consider that these have been mechanically
induced.28f
References
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