Riera Andres Ricardo Perez, Uchida Augusto Hiroshi, Schapachnik Edgardo, Dubner Sergio, Zhang Li, Filho Celso Ferreira, Ferreira Celso, Ferrara Dardo E, de Luna Antoni Bayes, Moffa Paulo Jorge
Electro-Vectorcardigraphic Section, ABC Medical School, ABC Foundation, Santo Andre - Sao Paulo, Brazil.
Indian Pacing Electrophysiol J. 2008 Apr 1;8(2):114-28.
There are several papers in literature that prove in a conclusive and incontestable way, that the left branch of the His bundle, in most instances (85% of the cases) splits into three fascicles of variable morphological pattern, and not into two: left anterior fascicle (LAF), left posterior fascicle (LPF), and left septal fascicle (LSF). The abovementioned papers have anatomical, histological, anatomo-pathological, electrocardiographic, and vectocardiographic, body surface potential mapping or ECG potential mapping and electrophysiological foundation.Additionally, the mentioned papers have been performed both in animal models (dogs) and in the human heart.Several clinical papers have shown that the left septal fascicular block (LSFB) may occur intermittently or transitorily as a consequence of a temporary dromotropic alteration, constituting an aberrant ventricular conduction, rate-dependent or by the application of atrial extra-stimuli, or naturally during the acute phase of infarction when this involves the anterior descending artery, before the septal perforating artery that supplies the central portion of the septum, where the mentioned LSF runs.The ECG/VCG manifestation of LSFB consists in anterior shift of electromotive forces, known as Prominent Anterior Forces (PAF), which can hardly be diagnosed in the clinical absence of other causes capable of causing PAF, such as the normal variant by counterclockwise rotation of the heart on its longitudinal axis, in right ventricular enlargement, in the dorsal or lateral infarction of the new nomenclature, in type-A WPW, in CRBBB, and others. In this historical manuscript, we review in a sequential fashion, the main findings that confirmed the unequivocal existence of this unjustifiably "forgotten" dromotropic disorder.In the developed countries, its most important cause is coronary insufficiency, particularly the proximal involvement of the left anterior descending coronary artery, and in Latin America, Chagas disease.
文献中有几篇论文以确凿且无可争议的方式证明，希氏束左支在大多数情况下（85%的病例）分为形态各异的三个束支，而非两个：左前分支（LAF）、左后分支（LPF）和左间隔分支（LSF）。上述论文具有解剖学、组织学、解剖病理学、心电图、心电向量图、体表电位标测或心电图电位标测以及电生理学依据。此外，上述研究在动物模型（狗）和人体心脏中均已开展。多篇临床论文表明，左间隔分支阻滞（LSFB）可能由于暂时的变时性改变而间歇性或短暂出现，构成异常心室传导，与心率相关或由心房额外刺激引起，或者自然发生在梗死急性期，当梗死累及前降支动脉，在供应间隔中央部分（上述LSF走行于此）的间隔穿支动脉之前。LSFB的心电图/心电向量图表现为电动势向前移位，即所谓的显著前向力（PAF），在临床缺乏其他能够导致PAF的原因时，很难诊断，如心脏纵轴逆时针旋转的正常变异、右心室扩大、新命名法中的后壁或侧壁梗死、A型预激综合征、完全性右束支传导阻滞等。在这篇历史性手稿中，我们按顺序回顾了主要研究结果，这些结果证实了这种被不合理地“遗忘”的变时性障碍的明确存在。在发达国家，其最重要的原因是冠状动脉供血不足，尤其是左前降支冠状动脉近端受累，而在拉丁美洲，主要原因是恰加斯病。
