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\begin{document}

\title{Left Ventricular Systolic Motion Pattern Differs Among Patients with
Left Bundle Branch Block Patterns}



\author[1]{Yan Chen}%
\author[1]{Yanjuan Zhang}%
\author[1]{Di Xu}%
\author[2]{Chun Chen}%
\author[3]{changqing miao}%
\author[1]{Huan Tang}%
\author[1]{Beibei Ge}%
\author[1]{Yan Shen}%
\author[1]{Jing Yao}%
\affil[1]{Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital}%
\affil[2]{the First Affiliated Hospital of Nanjing Medical University}%
\affil[3]{Jiangsu Province People's Hospital and Nanjing Medical University First Affiliated Hospital}%


\vspace{-1em}



  
  \date{June 13, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background: The electrical activation patterns in pacemaker rhythm, type
B Wolff-Parkinson-White syndrome, and premature ventricular complexes
originating from the right ventricular outflow tract are similar to
those of the complete left bundle branch block and can be considered as
LBBB patterns. Methods: Two-dimensional speckle tracking was used to
evaluate peak value and time to peak value of the LV twist, LV apex
rotation, and LV base rotation in patients with PM, B-WPW, RVOT-PVC,
CLBBB, and in age-matched control subjects. The apical-basal rotation
delay was calculated as the index of LV dyssynchrony. Results: The LV
motion patterns were altered in all patients compared to the control
groups. Patients with PM and CLBBB had a similar LV motion pattern with
a reduced peak value of LV apex rotation and LV twist. Patients with
B-WPW demonstrated the opposite trend in the reduction of LV rotation
peak value, which was more dominant in the basal layer. The most
impairment in the LV twist/rotation peak value was identified in
patients with RVOT-PVC. Compared to the control group, the apical-basal
rotation delay was prolonged in patients with CLBBB, followed by those
with B-WPW, RVAP, and RVOT-PVC. Conclusions: The LV motion patterns were
different among patients with different patterns of LBBB. CLBBB and PM
demonstrated a reduction in LV twist/rotation that was pronounced in the
apical layer, B-WPW showed a reduction in the basal layer, and RVOT-PVC
in both layers. CLBBB had the most pronounced LV apical-basal rotation
dyssynchrony.%
\end{abstract}%



\sloppy


Left Ventricular Systolic Motion Pattern Differs Among Patients with
Left Bundle Branch Block Patterns

\textbf{Yan Chen\textsuperscript{1,2}, Yanjuan Zhang\textsuperscript{1},
Di Xu\textsuperscript{1}, Chun Chen\textsuperscript{1}; Changqing
Miao\textsuperscript{1}, Huan Tang\textsuperscript{1}, Beibei
Ge\textsuperscript{1}, Yan Shen \textsuperscript{1}, Jing
Yao\textsuperscript{1}}

\textsuperscript{\textbf{1}} Department of Cardiology, The First
Affiliated Hospital of Nanjing Medical University, Nanjing 210029,
Jiangsu,P.R. China

\textsuperscript{2}Department of Cardiology, Affiliated Hospital of
Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu, P.R.
China

Corresponding author: Jing Yao

Tel: +8618901588727

E-mail:echoluyao@163.com

Co-first author: Yanjuan Zhang

\textbf{Abstract}

\textbf{Background:} The electrical activation patterns in pacemaker
rhythm (PM), type B Wolff-Parkinson-White syndrome (B-WPW), and
premature ventricular complexes originating from the right ventricular
outflow tract (RVOT-PVC) are similar to those of the complete left
bundle branch block (CLBBB) and can be considered as LBBB patterns. Left
ventricular (LV) motion pattern is a sensitive indicator of LV systolic
function. A comparison of LV motion patterns in patients with different
LBBB patterns has not been performed.

\textbf{Methods:} Two-dimensional speckle tracking was used to evaluate
peak value and time to peak value of the LV twist, LV apex rotation, and
LV base rotation in patients with PM (n=45), B-WPW (n=38), RVOT-PVC
(n=30), and CLBBB with normal LV ejection fraction (n=28), and in
age-matched control subjects (n=120). The time to peak value was
expressed as a percentage relative to the R-R interval. The apical-basal
rotation delay was calculated as the index of LV dyssynchrony.

\textbf{Results:} The LV motion patterns, including the reduction in LV
twist peak value, apical/basal rotation, and dyssynchrony of LV
apical-basal rotation, were altered in all patients compared to the
control groups. Patients with PM and CLBBB had a similar LV motion
pattern with a reduced peak value of LV apex rotation and LV twist.
Patients with B-WPW demonstrated the opposite trend in the reduction of
LV rotation peak value, which was more dominant in the basal layer. The
most impairment in the LV twist/rotation peak value was identified in
patients with RVOT-PVC. Compared to the control group, the apical-basal
rotation delay was prolonged in patients with CLBBB, followed by those
with B-WPW, RVAP, and RVOT-PVC.

\textbf{Conclusions:} The LV motion patterns were different among
patients with different patterns of LBBB. CLBBB and PM demonstrated a
reduction in LV twist/rotation that was pronounced in the apical layer,
B-WPW showed a reduction in the basal layer, and RVOT-PVC in both
layers. CLBBB had the most pronounced LV apical-basal rotation
dyssynchrony.

\textbf{Keywords:}

Echocardiography, Left bundle branch block pattern, Left ventricular
twist, Left ventricular rotation, Left ventricular motion

\textbf{1.Introduction}

Left bundle branch block (LBBB) is a common cardiac arrhythmia. The
incidence of idiopathic LBBB in a general population is about 0.1\%. It
has been reported that approximately 90\% of LBBB cases are associated
with cardiovascular disease\textsuperscript{{[}1{]}}, and about 25\% of
heart failure patients have a history of LBBB\textsuperscript{{[}2{]}}.
Wide QRS complex duration and deterioration of left ventricular (LV)
systolic and diastolic functions occurring due to LBBB are risk factors
for the development and progression of heart failure. Ventricular
dysfunction caused by LBBB results in paradoxical motion of the septum,
intra- and inter-ventricular mechanical dyssynchrony, and ultimately
myocardial remodeling\textsuperscript{{[}3{]}}. The alterations in LV
mechanical activation sequences in LBBB patients are attributed to
abnormal electrical activation. Due to the blockage of the left bundle
branch, electricity is conducted through normal cardiac myocytes in the
LV free wall instead of Purkinje fibers. There are three other types of
conduction disorders with a similar electricity conduction
pattern---pacemaker rhythm (PM), type B Wolff-Parkinson-White syndrome
(B-WPW), and premature ventricular complexes originating from the right
ventricle (RVOT-PVC). Therefore, all four abnormal conditions were
defined as LBBB pattern conduction disorders in the present study.

Two-dimensional speckle tracking echocardiography (2D-STE) is a
noninvasive method used to analyze deformation of the myocardium without
angle dependence. Good correlation between 2D-STE and cardiac magnetic
resonance in the measurement of LV twist has been
confirmed\textsuperscript{{[}4, 5{]}}. A number of studies have assessed
twist mechanisms of LV in patients with LBBB\textsuperscript{{[}6-8{]}}.
However, none of the studies have evaluated and compared the torsion
pattern in patients with LBBB pattern conduction disorders, including
CLBBB, pacemaker rhythm, B-WPW, and RV-PVC. Therefore, the present study
was designed to elucidate the varieties of twist patterns in the above
four LBBB types.

\textbf{2. Methods}

2.1 Patient selection and data collection

The present study included 141 patients who underwent echocardiography
in the First Affiliated Hospital of Nanjing Medical University
between~December 2010 and February 2018. A total of 28 patients with
complete LBBB (CLBBB) and preserved LV ejection fraction (EF) were
included using a conventional characteristic electrocardiogram (ECG)
definition as follows: QRS duration [?]120 ms; absent Q waves in leads I,
V5, and V6; presence of QS or rS in leads V1 and V2; and broad and
notched R-waves in leads I, aVL, V5, and V6 (group CLBBB). There were 45
patients who underwent DDD pacemaker implantation due to a 3rd degree AV
block (group PM). All patients in the PM group were pacemaker-dependent
and the right ventricle apex served as the ventricle lead implantation
location. A total of 38 patients with B-WPW, who underwent
radiofrequency ablation with preoperative ECG characteristics including
PR interval of \textless{}120 ms, QRS duration of \textgreater{}120 ms,
and the presence of delta waves in QRS complexes, participated in the
study. An electrophysiological examination demonstrated the existence of
right accessory pathways (group B-WPW). Thirty patients had premature
ventricular complexes originating from the right ventricular outflow
tract (group RVOT-PVC). RVOT-PVC was defined as an ECG parameter of the
LBBB contour in V1 and an inferior axis in the frontal plane with a
frequency of \textgreater{}5 bpm (group
RVOT-PVC)\textsuperscript{{[}9{]}}.

Exclusion criteria included congenital heart disease, valvular heart
disease, and coronary heart disease. No antiarrhythmic drugs were taken
before examination in all selected patients. During patient screening,
it was discovered that demographic characteristic of the LBBB group were
comparable to those of the PM group. Patients in the PM and LBBB groups
were older than those in the RVOT-PVC group, and the average age in the
B-WPW group was lowest among all groups. To reduce the influence of age,
control subjects matched by age and gender in each group were selected.
The characteristics of the Control Group 1 were compared to those of the
CLBBB and PM groups. The characteristics of the Control Groups 2 and 3
were compared to those of the B-WPW and RVOT-PVC groups, respectively.
Informed consent was obtained from all of the subjects. This study was
approved by the institutional review board. All control subjects
underwent ECG, echocardiography, and laboratory examinations. The
gender, age, height (cm), weight (kg), heart rate (bpm), and QRS
duration were recorded.

2.2 Image acquisition and standard echocardiography studies

Transthoracic echocardiograms were performed using Vivid E9 (GE Medical
Systems, Milwaukee, WI, USA) with M5S probe. The frame rate ([?]60
frames/s), probe frequency (range: 1.5--4.0 MHz), and depth (range:
15--17 cm) were adjusted at end- expiratory for better image quality.
All subjects were examined in the left lateral decubitus position. The
routine standard echocardiographic measurements included LV
end-diastolic dimension (LVEDD) and end-systolic dimension (LVESD) from
the M-mode or 2D imaging. LVEF was calculated using a biplane Simpson's
method from images acquired in apical four- and two-chamber views. The
2D grayscale dynamic images were acquired in the parasternal short-axis
view at the mitral valve and apex level for three consecutive cardiac
cycles.

2.3 2D speckle tracking imaging analysis

All images were stored digitally on disks and then analyzed offline
using dedicated software (EchoPac platform, Version 11.0.0, GE Vingmed).
Endocardial borders were traced manually in both basal and apical levels
of the parasternal short-axis view. LV torsion-time, apical
rotation-time, and basal rotation-time curves were generated
automatically. The following parameters were measured on the curves:
peak basal rotation (Rot-B), time to peak basal rotation (T-RotB) (time
from the onset of QRS complex to peak basal rotation), peak apical
rotation (Rot-A), time to peak apical rotation (T-RotA) (time from the
onset of QRS complex to peak apical rotation), peak LV twist (LVtwist),
and time to peak LV twist (T-LVtwist) (time from the onset of QRS
complex to peak LV twist). In order to reduce the influence of the heart
rate, the above time interval parameters were expressed as percentages
relative to the R-R interval (Figures 1 and 2). Time intervals between
the peak apical and basal rotations were calculated.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
&\tabularnewline
\textbf{Figure 1.} Endocardial borders were traced at basal (A) and
apical (B) levels of parasternal short-axis view and rotation-time
curves were generated. Color-coded solid curves represent different
layer segments, and white-dotted curve represents layer value. &
\textbf{Figure 1.} Endocardial borders were traced at basal (A) and
apical (B) levels of parasternal short-axis view and rotation-time
curves were generated. Color-coded solid curves represent different
layer segments, and white-dotted curve represents layer
value.\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\tabularnewline
\textbf{Figure 2.} Basal rotation-time curve (pink), apical
rotation-time curve (blue), and LV twist-time curve (white) were
obtained using 2D-STE. Peak of basal rotation (Rot-B), apical rotation
(Rot-A), LV twist (LVtwist), and time to peak value were measured on
corresponding curves. Time to peak values was standardized using R-R
interval. LV: left ventricle; STE: speckle tracking
echocardiography.\tabularnewline
\bottomrule
\end{longtable}

2.4 Statistical analysis

Continuous variables were expressed as mean\selectlanguage{ngerman}±standard deviation (SD),
while categorical data were expressed as frequencies and percentages.
Comparison of twist parameters between patients in each group and
corresponding control groups was performed using an unpaired t-test.
Comparison of categorical variables was performed using Pearson's
chi-square test. All statistical tests were two-sided and performed
using the SPSS software (SPSS version 22.0 for Windows), where
p\textless{}0.05 was considered statistically significant.

Offline analysis of all subjects was performed by a single observer. LV
twist parameters for 20 subjects selected randomly were reanalyzed by
the same observer one week later. The 2D-STE analysis was repeated by
another observer in these selected subjects at the same time. The intra-
and inter-observer variability analysis was performed using Blant-Altman
analysis. Peak LV twist showed a high inter- and intra-observer
agreement on the Bland-Altman chart. The Bland-Altman drawing analysis
method showed that the mean intra- and inter-observer differences in
peak LV twist were -0.07° and 0.07°, respectively. The 95\% confidence
intervals (CIs) were in the range of -1.33° to 1.20° and -1.01° to
1.16°, respectively. It was demonstrated that the LV twist/rotation
parameters had good intra- and inter-observer consistency (Figure 3).\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
A\tabularnewline
B\tabularnewline
\textbf{Figure 3. Intra- and inter-observer consistency of LV twist
parameters.} Note: Bland-Altman analysis for estimating the accuracy of
peak LV twist measurements by a single observer (A) and two different
observers (B). Blue solid line indicates mean, and red dotted lines
indicates two SD limits.\tabularnewline
\bottomrule
\end{longtable}

\textbf{3. Results}

3.1. Baseline characteristics

The study comprised 141 patients with LBBB pattern (28 with CLBBB, 45
with pacemaker rhythm, 38 with B-WPW, and 30 with RVOT-PVCs), as well as
120 control subjects (49 in CON1 (control group 1), 31 in CON2 (control
group 2), and 40 in CON3 (control group 3)). Compared to the
corresponding control group, there was no significant difference in age,
gender, height, and body weight in the arrhythmia group. Patients with
pacemaker rhythm had a lower heart rate compared to the subjects in the
CON1 group (64.4\selectlanguage{ngerman}±8.0 bpm vs. 71.8±10.5 bpm, P\textless{}0.001; Table 1).

3.2. Standard echocardiographic parameters

Echocardiographic variables are summarized in Table 2. Patients in the
CLBBB, PM, B-WPW, and RVOT-PVC groups showed enlarged LVEDD and LVESD
compared to their corresponding control groups (all P\textless{}0.05).
There were no differences in LVEF between the CLBBB, PM (65.2±3.9\% and
63.9±4.8\%), and CON1 (65.3±3.4\%) groups. Patients with B-WPW had a
significantly lower LVEF compared to those in the CON2 group (55.6±7.8\%
vs. 64.8±4.7\%, P\textless{}0.001). Compared to the CON3 group, LVEF in
the RVOT-PVC group was significantly lower (49.5±14.9\% vs. 66.0±4.0\%,
P\textless{}0.001; Figure 4).\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\tabularnewline
\textbf{Figure 4. LVEF in patients with LBBB patterns and control
subjects.} Note: Data in CON1 group were used to compare to patients
with CLBBB and DDD PM implantation. Data in CON2 group were used to
compare to patients with B-WPW. Data in CON3 group were used to compare
to patients with RVOT-PVC. All data were compared to the corresponding
control group. *represents P\textless{}0.05.\tabularnewline
\bottomrule
\end{longtable}

3.3. LV twist parameters

3.3.1 LV twist/rotation parameters in patients with LBBB

Compared to the CON1 group, a significant reduction was found in peak
apical rotation (6.0\selectlanguage{ngerman}±4.5° vs. 9.6±4.2°, P=0.001) and LV twist (10.4±5.9°
vs. 16.1±5.6°, P\textless{}0.001) in the CLBBB group. Peak basal
rotation remained unaltered. T-RotA and T-LVtwist were longer than those
in the CON1 group. The time interval between peak apical and basal
rotation was significantly longer in the CLBBB group compared to the
control group (17.2±13.3\% vs. 6.6±6.3\%, P\textless{}0.001; Table 3).

3.3.2 LV twist/rotation parameters in patients with pacemaker rhythm

In patients with pacemaker rhythm, peak apical rotation (6.2±5.2° vs.
9.6±4.2°, P=0.001) and peak LV twist (11.2±5.1° vs. 16.1±5.6°,
P\textless{}0.001) were reduced, accompanied by a longer T-LVtwist
(54.3±9.3\% vs. 46.3±7.9\%, P\textless{}0.001) compared to the control
subjects. In addition, the time interval between peak apical and basal
rotations was significantly longer (10.4±8.2\% vs. 6.6±6.3\%, P=0.042;
Table 3).

3.3.3 LV twist/rotation parameters in patients with B-WPW

Compared to the CON2 group, a significant reduction was observed in peak
apical rotation (7.2±6.2° vs. 10.3±4.2°, P=0.011), basal rotation
(-3.0±3.6° vs. -7.0±3.3°, P\textless{}0.001), and twist (8.5±9.0° vs.
16.9±4.3°, P\textless{}0.001) in the B-WPW group. The TTP-B was shorter
(41.8±11.7\% vs. 48.9±9.2\%, P=0.004) than that in the CON2 group
subjects. The time interval between peak apical and basal rotations was
prolonged significantly (14.0±13.4\% vs. 7.1±8.0\%, P=0.008; Table 3).

3.3.4 LV twist/rotation parameters in patients with RVOT-PVCs

Compared to the control subjects, RVOT-PVC patients showed a
significantly lower peak basal rotation (-0.6±4.4° vs. -5.3±3.8°,
P\textless{}0.001), apical rotation (3.9±7.2° vs. 9.5±3.2°,
P\textless{}0.001), and LV twist (4.4±9.6° vs. 14.0±4.1°,
P\textless{}0.001). However, the time interval between peak apical and
basal rotations showed no significant difference (Table 3).

3.3.5 Comprehensive analysis of LV twist parameters

3.3.5.1 Twist/rotation changes in different LV layers

The LV twist/rotation curves of the control group were characterized.
The global LV and LV apex twists/rotates counterclockwise (black and
blue positive curves in Figure 5), while the LV base rotates clockwise
(red negative curves in Figure 5) during systole. The twist/rotation
reaches peak value at the end of the contraction and then gradually
untwist back to the baseline during diastole.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Group} & \textbf{Schematic diagram} & \textbf{ECG} &
\textbf{Twist/rotation-time curve}\tabularnewline
\textbf{Control} & & &\tabularnewline
\textbf{LBBB} & & &\tabularnewline
\textbf{PM} & & &\tabularnewline
\textbf{B-WPW} & & &\tabularnewline
\textbf{RVOT-} \textbf{PVC} & & &\tabularnewline
\textbf{Figure 5} & Schematic diagram (left), ECG (middle), and example
of torsion/rotation-time curve (right) in each group. LV torsion Apex
rotation Base rotation & Schematic diagram (left), ECG (middle), and
example of torsion/rotation-time curve (right) in each group. LV torsion
Apex rotation Base rotation & Schematic diagram (left), ECG (middle),
and example of torsion/rotation-time curve (right) in each group. LV
torsion Apex rotation Base rotation\tabularnewline
\bottomrule
\end{longtable}

Compared to the control groups, LV motion pattern was altered in all
patients, including the reduction in peak LV twist, peak apical/basal
rotation, and dyssynchrony of LV apical-basal rotation (Figure 5).
Patients with LBBB or pacemaker rhythm presented with a similar LV
motion pattern, where reduced rotation was more dominant in the apical
layer. In contrast, patients with B-WPW demonstrated the opposite trend
with a reduction in LV rotation peak value, which is more dominant in
the basal layer. The most predominant impairment in the peak value of
the LV twist/rotation was found in patients with RVOT-PVC, which was
prominent in both apical and basal layers (Figure 6).\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
A\tabularnewline
B\tabularnewline
C\tabularnewline
\textbf{Figure 6. Peak value of LV twist (A), apical rotation (B), and
basal rotation (C) in patients with LBBB pattern and control subjects.}
Note: Data in CON1 group were used to compare to patients with CLBBB and
DDD PM implantation. Data in CON2 group were used to compare to patients
with B-WPW. Data in CON3 group were used to compare to patients with
RVOT-PVC. All data were compared to the corresponding control group.
*represents P\textless{}0.05.\tabularnewline
\bottomrule
\end{longtable}

3.3.5.2 Synchrony of LV rotation in different layers

In the control groups, the rotation of LV base and apex reached the peak
value synchronously (Figure 4). In patients with CLBBB, time to peak LV
twist was prolonged (63.2\selectlanguage{ngerman}±12.2\% vs. 46.3±7.9\%, P\textless{}0.001),
which manifested as the prolonged time to peak apical rotation
(62.0±17.7\% vs. 47.8±10.1\%, P=0.016). The apical and basal rotation
movements were out of sync, which manifested as a prolonged TDA-B
(17.2±13.3\% vs. 6.6±6.3\%, P\textless{}0.001). In patients with
pacemaker rhythm, the rotation of the apex and base was not
synchronized, presenting with a prolonged TDA-B (10.4±8.2\% vs.
6.6±6.3\%, P=0.042). Time to peak basal rotation in patients with B-WPW
was shortened (41.8±11.7\% vs. 48.9±9.2\%, P=0.004) and had a prolonged
TDA-B, which represented the dyssynchrony of the apical and basal
rotations (14.0±13.4\% vs. 7.1±8.0\%, P=0.008). Patients with RVOT-PVC
showed a synchronous rotation of the apex and base accompanied by a
change in TDA-B (9.3±11.9\% vs. 7.9±8.1\%, P=0.599). This association
was not significant (Figure 7).\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
A\tabularnewline
B\tabularnewline
C\tabularnewline
D\tabularnewline
\textbf{Figure 7. Time to peak value of LV twist (A), apical rotation
(B), and basal rotation (C), and time interval between apical and basal
rotation (D) in patients with LBBB patterns and control subjects} Note:
Data in CON1 group were used to compare to patients with CLBBB and DDD
PM implantation. Data in CON2 group were used to compare to patients
with B-WPW. Data in CON3 group were used to compare to patients with
RVOT-PVC. All data were compared to the corresponding control group.
*represents P\textless{}0.05.\tabularnewline
\bottomrule
\end{longtable}

3.4. QRS complex duration

Patients in the CLBBB, PM, B-WPW, and RVOT-PVC groups had a prolonged
QRS complex duration compared to their corresponding control groups (all
P\textless{}0.001; Figure 8).\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\tabularnewline
\textbf{Figure 8. QRS complex duration in patients with LBBB patterns
and control subjects} Note: Data in CON1 group were used to compare to
patients with CLBBB and DDD PM implantation. Data in CON2 group were
used to compare to patients with B-WPW. Data in CON3 group were used to
compare to patients with RVOT-PVC. All data were compared to the
corresponding control group. *represents
P\textless{}0.05.\tabularnewline
\bottomrule
\end{longtable}

\textbf{4. Discussion}

Coordinated contraction of myocardial fibers in different directions
leads to normal ventricular contraction. Contractions of oblique
myocardial fibers constitute the main mechanism of LV twist, which is
characterized by the opposite rotation of the apex and base. As observed
from the apex, the LV base rotates clockwise during systole, while the
LV apex rotates counterclockwise. LV twist was calculated as the
instantaneous net difference between basal and apical rotations. In
addition to the shortening and thickening of the myocardial fibers, the
LV twist plays an important role in cardiac systolic function.

LVEF is the most commonly used parameter for LV systolic function and is
identified as a cornerstone of clinical therapeutic strategies. It is
load-dependent and prone to inaccuracies, especially in patients with
LBBB. Asynchronous activation of LV among these patients can lead to
subtle abnormalities in LV systolic function, which has a low
sensitivity when using LVEF as the assessment indicator. LVEF relies on
geometric assumptions and alterations in LV volumes and dimensions.
Therefore, it indirectly reflects LV systolic function rather than the
intrinsic myocardial contractility\textsuperscript{{[}10{]}}.

The LV twist is a sensitive indicator of LV systolic function, which has
been established in various populations with multifarious
diseases\textsuperscript{{[}11-14{]}}. Heart failure patients scheduled
for cardiac resynchronization therapy (CRT) were prospectively studied
by Chiara et al.\textsuperscript{{[}15{]}}. They found that alterations
in LV twist take place earlier than variations in LV volumes and LVEF.
Patients who experience a greater acute modification of twist when
switching from CRT-off to CRT-on will benefit more from LV reverse
remodeling. This indicates that LV twist parameters can help in
prognosis during early follow-up in heart failure patients with CRT.
Mohamed et al. have investigated LV twist in patients with non-ischemic
dilated cardiomyopathy (DCM). They showed that patients with reduced LV
twist and apical rotation at baseline were more often hospitalized for
worsening cardiac events during the follow-up period than patients with
relatively preserved rotational mechanics, suggesting that LV twist has
prognostic relevance in non-ischemic DCM patients. The reduced LV twist
indicated a more rigid ventricle, which appropriately reflects the
greater disease severity\textsuperscript{{[}16{]}}. In addition to
cardiac disease, LV twist parameters are also used for early detection
of myocardial dysfunction in other diseases. Fu-Wei et al. have
investigated LV twist in patients with autoimmune diseases. They found
that patients with preserved LVEF exhibited a significantly impaired LV
twist attributed to attenuation in apical rotation, suggesting that
twist parameters are changed before LVEF is altered and are more
sensitive indicators of diagnosing systolic
dysfunction\textsuperscript{{[}17{]}}. No studies have evaluated LV
twist mechanics in patients with LBBB pattern conduction disorders,
which include CLBBB, pacemaker rhythm, B-WPW, and RVOT-PVC.

The components of a normal conducting system include the sinoatrial
node, atrioventricular node, bundle of His, right and left branches, and
Purkinje fibers. The electrical impulse is first picked up by pacemaker
cells in the sinoatrial node due to its rapid inherent rhythm and
movement to the atrioventricular node through internodal pathways. Then,
it passes the bundle of His and onward to the right and left bundle
branches. The impulse eventually quickly and almost uniformly spreads
out to the ventricular muscle.

In patients with LBBB, the impulse travels from the atrioventricular
node to the right bundle branches, and the septum is activated from
right to left. Then, activation of LV free wall occurs slowly via
ordinary ventricular muscle instead of Purkinje fibers. Myocardium at
the apex layer is activated earlier, and the posterior lateral wall at
base layer is the latest excitation location. The rotation at that apex
that contracted earlier decreases. At the same time, dyssynchrony of
intraventricular excitation results in a decrease in LV twist. LV twist
can be used as a potential clinical marker of myocardial dysfunction in
isolated LBBB patients with preserved LVEF{[}6{]}. Patients with heart
failure accompanied by LBBB who received resynchronization therapy
showed a shorter delay time between the septum and left posterior wall,
as well as significantly improved LVEF and mitral
regurgitation\textsuperscript{{[}18, 19{]}}. The other three types of
conduction disorders, including pacemaker rhythm, B-WPW, and RVOT-PVC,
show an LV electrical activation pattern similar to that of CLBBB
demonstrated in clinical work.

4.1. Right ventricular apical pacing

Right ventricular apex has been the most common pacing location due to
the abundant trabeculae, which is convenient for electrode fixation.
Various clinical and animal studies have shown that long-term right
ventricular apical pacing can increase the incidence of atrial
fibrillation, lead to LV remodeling, and eventually decrease cardiac
function\textsuperscript{{[}20-24{]}}. The present study found that LV
twist and apical rotation decreased significantly in patients with
pacemaker rhythm. The time interval between apical and basal rotations
was prolonged, which may lead to uncoordinated contraction of the LV
myocardium. These findings were consistent with the study by Koh et
al.\textsuperscript{{[}25{]}}. The abnormal electrical activation
sequence is key for the inhibition of LV twist in such patients. The
pacemaker lead inserts were first excited in the right ventricular apex.
Electrical excitation is transmitted from the apex to the septum
contrary to the sinus rhythm pattern and then propagates through the
myocardium to the LV free wall. The abnormal activation process in
pacemaker rhythm is similar to that in LBBB. This pacemaker rhythm is
known as iatrogenic LBBB. The decreased LV twist in RVAP patients is
related to perfusion defects mainly over the inferior and apical
segments\textsuperscript{{[}26{]}}. Long-term regional perfusion defects
may lead to decreased contractility of myocardial fibers in the apex,
thereby inhibiting rotation in the apex of the heart. Studies on the His
bundle pacing revealed that electrical activation expands uniformly
along the bundle of His and Purkinje fibers to both right and left
ventricles, which can reduce ventricular dyssynchrony and reverse
ventricular remodeling in comparison to right ventricular apex
pacing\textsuperscript{{[}27, 28{]}}.

4.2. B-WPW

The B-WPW is a congenital heart disease with an incidence of
1--3%0\textsuperscript{{[}29{]}}. The incidence of preexcitation
cardiomyopathy is highest in B-WPW patients with right septal accessory
pathways\textsuperscript{{[}30{]}}. The present study found that LV
twist, apical rotation, and basal rotation were all reduced in patients
with B-WPW. Compared to the reduction at the apex, the rotation
decreased more at the base. Time to peak basal rotation was shorter than
that at the apex, which suggests dyssynchrony of intraventricular
contraction, accompanied by wider QRS duration and reduced LVEF. In
patients with B-WPW, right ventricular anterior wall is first activated
via the right accessory pathway. Then, electrical activation is
transmitted from the right ventricle to the left slowly, similar to the
LBBB pattern. Our previous studies\textsuperscript{{[}31{]}} have
revealed that LV diameter and LVEF can be reversed in patients with
B-WPW after successful radiofrequency ablation. The LV twist, apical and
basal rotation, as well as apical-basal rotation synchrony improved
significantly after ablation.

4.3. Premature ventricular complexes from the right ventricular outflow
tract (RVOT-PVC)

Frequent PVC is one of the most common arrhythmias. More than 80\% of
idiopathic ventricular tachycardia or PVC cases originate from the RVOT,
and about 16\% of them develop into polymorphic ventricular tachycardia
and ventricular fibrillation. The present findings revealed that during
PVC originating from RVOT, both apical and basal rotations were much
more altered and accompanied by a wide QRS duration and significant
decrease in LVEF. In RVOT-PVC, the septum is close to the ectopic
excitation points and is therefore excited first. Then, the electrical
activation transmits from right to left through the ventricular muscle.
The electricity conduction pattern during RVOT-PVC was similar to that
during LBBB. Frequent PVCs are believed to cause a significant decrease
in LVEF, as well as pacing from the right ventricular apex in patients
with pacemaker dependency\textsuperscript{{[}32{]}}. Clinical studies
have found that long-term frequent RVOT-PVCs reduce stroke volume,
aggravate LV remodeling and mitral regurgitation, and finally lead to
the reduction in LVEF. Patients with frequent PVCs were associated with
LV dilation and reduced LVEF. After a successful radiofrequency
ablation, both LV dimension and LVEF improved
significantly\textsuperscript{{[}33,34{]}}.

The characteristics of the above LBBB pattern conduction disorders can
be summarized as shown further. First, the electrical activation of LV
is not transmitted through the His bundle and Purkinje fibers rapidly
and uniformly, but slowly through the ordinary ventricular muscle from
right to left. Second, LV twist motion shows heterogenetic alteration in
the four types of conduction disorders. Patients with LBBB or pacemaker
rhythm manifested as having decreased apical rotation, while patients
with B-WPW were mainly characterized by the reduction in basal rotation
and a prolonged peak value time. The attenuation in rotation for both
basal and apical layers in RVOT-PVC patients was the most significant
among all groups. By analyzing the characteristics of the electricity
conduction pattern, it was found that in patients with LBBB or pacemaker
rhythm, LV apex myocardium was excited and contracted earlier than the
rest of the LV muscle. Then, the impulse gradually expanded through the
LV free wall, while the basal LV layer was excited later. In patients
with B-WPW, myocardium at the base layer close to the right accessory
pathway was activated first. Then, electrical activation was slowly
transmitted from the right ventricle to the left. The apical layer was
activated relatively late. Prinzen et al have investigated dogs with
different pacing patterns and found that the fiber strain and blood flow
are both impaired in the early excited
myocardium\textsuperscript{{[}35{]}}. Our previous study on the
influence of pacing location on cardiac motion pattern and function
found that the earlier contracting segment resulted in a reduced peak
longitudinal strain\textsuperscript{{[}36{]}}. When the regional
myocardium activates in advance, the blood flows to the excitation site
relatively slowly. Rotation is decreased at the myocardium with poor
perfusion according to the Frank-Starling mechanism. At the same time,
the pressure in the LV cavity remains low when regional myocardium is
activated in advance. Myocardial fibers in areas that activated late are
passively elongated with relatively enhanced contractility. The
reduction in the regional myocardium in patients with LBBB pattern
conduction disorders was a consequence of reduced perfusion and
myocardial fiber contractility. In patients with LBBB pattern conduction
disorders, regional myocardium (apex or base layer) is activated in
advance. The decrease in rotation in pre-excited myocardium and
intraventricular dyssynchrony leads to a reduction in global LV twist
and myocardial contracting efficiency, which eventually results in a
decrease in stroke volume and cardiac function. In patients with LBBB
pattern conduction disorders, slight changes in myocardial movements can
lead to large alterations in LV twist prior to LVEF. Early
quantification of impaired LV twist parameters can assist with clinical
vigilance and therapeutic decisions, especially in patients with LBBB
pattern conduction disorders and preserved LVEF.

4.4 Study limitations

There are several limitations that need to be acknowledged in the
present study. First, the enrollment in this case-control study was
relatively low. Second, the influence of the subjects' medication use
was not considered. Third, the endocardial borders were manually traced
when the LV cavity was occluded at the end of the contraction at the
apical short-axis level and its consistency could not be ensured among
all subjects.

\textbf{5.Conclusions}

The present investigation represents the first case-control study to
compare different LBBB pattern conduction disorders with age-matched
control subjects in aspects of LV twist motion pattern.

LV twist motion shows heterogenetic alteration in four types of
conduction disorders. Patients with LBBB or pacemaker rhythm manifested
as having decreased apical rotation, while patients with B-WPW were
mainly characterized by the reduction in basal rotation and a prolonged
peak value time. The attenuation in rotation for both basal and apical
layers in RVOT-PVC patients was the most significant among all groups.
Quantification of LV twist parameters analyzed using 2D-STE enables a
detailed characterization of the contraction pattern in patients with
LBBB pattern conduction disorders.

\textbf{Table 1.Baseline characteristics in patients with LBBB patterns
and controls.}\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Groups\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
CON1 (n=49)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
CON2 (n=40)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
CON3 (n=31)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
CLBBB (n=28)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
PM (n=45)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
B-WPW (n=38)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
RVOT-PVC (n=30)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textbf{Male (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
51\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
65\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
48\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
50\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
47\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
55\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
50\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Age(yrs)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
70.6 \selectlanguage{ngerman}±10.0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
36.7 \selectlanguage{ngerman}±12.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
47.5 \selectlanguage{ngerman}±18.7\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
69.6 \selectlanguage{ngerman}±9.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
69.3 \selectlanguage{ngerman}±10.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
34.0 \selectlanguage{ngerman}±14.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
51.2 \selectlanguage{ngerman}±18.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\selectlanguage{english}\textbf{Height(cm)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
163.0 \selectlanguage{ngerman}±7.3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
167.3 \selectlanguage{ngerman}±8.9\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
163.1 \selectlanguage{ngerman}±5.4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
165.7 \selectlanguage{ngerman}±7.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
162.2 \selectlanguage{ngerman}±7.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
166.7 \selectlanguage{ngerman}±5.8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
164.5 \selectlanguage{ngerman}±7.2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\selectlanguage{english}\textbf{Weight(kg)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
65.8 \selectlanguage{ngerman}±9.9\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
61.5 \selectlanguage{ngerman}±11.7\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
66.8 \selectlanguage{ngerman}±8.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
62.9 \selectlanguage{ngerman}±12.8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
62.7 \selectlanguage{ngerman}±9.9\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
64.0 \selectlanguage{ngerman}±8.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
62.4 \selectlanguage{ngerman}±9.1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{HR (bpm)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
71.8 \selectlanguage{ngerman}±10.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
71.9 \selectlanguage{ngerman}±11.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
70.8 \selectlanguage{ngerman}±10.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
70.8 \selectlanguage{ngerman}±9.4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
64.4 \selectlanguage{ngerman}±8.0\textbf{*}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
73.0 \selectlanguage{ngerman}±10.3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
73.0 \selectlanguage{ngerman}±12.2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\selectlanguage{english}\textbf{QRS(ms)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
97.980 \selectlanguage{ngerman}±12.091\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
102.175 \selectlanguage{ngerman}±19.837\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
100.312 \selectlanguage{ngerman}±10.531\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
155.214\textbf{*} \selectlanguage{ngerman}±13.544\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
176.978\textbf{*} \selectlanguage{ngerman}±36.393\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
172.184\textbf{*} \selectlanguage{ngerman}±37.971\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
169.358\textbf{*} \selectlanguage{ngerman}±14.780\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}

Note: Data in CON1 group were used to compare to patients with CLBBB and
DDD PM implantation. Data in CON2 group were used to compare to patients
with B-WPW. Data in CON3 group were used to compare to patients with
RVOT-PVC. All data were compared to the corresponding control group.
*represents P\textless{}0.05.

\textbf{Table 2. Standard echocardiographic parameters in patients with
LBBB patterns and controls.}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P-value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P-value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P-value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P-value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CON1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CON2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CON3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CLBBB\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
PM\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
B-WPW\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
RVOT-PVC\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CLBBB vs. CON1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
PM vs. CON1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
B-WPW vs. CON2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
RVOT-PVC vs. CON3\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{LVEF (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
65.3 \selectlanguage{ngerman}±3.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
64.8 \selectlanguage{ngerman}±4.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
66.0 \selectlanguage{ngerman}±4.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
65.2 \selectlanguage{ngerman}±3.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
63.9 \selectlanguage{ngerman}±4.8\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
55.6 \selectlanguage{ngerman}±7.8\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
49.5 \selectlanguage{ngerman}±14.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.587\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.923\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{LVEDD(mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
45.8 \selectlanguage{ngerman}±3.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
45.4 \selectlanguage{ngerman}±3.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
46.0 \selectlanguage{ngerman}±2.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
49.4 \selectlanguage{ngerman}±6.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
47.8 \selectlanguage{ngerman}±3.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
48.0 \selectlanguage{ngerman}±5.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
51.5 \selectlanguage{ngerman}±4.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.009\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.013\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{LVESD(mm)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
29.2 \selectlanguage{ngerman}±2.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
29.4 \selectlanguage{ngerman}±2.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
28.5 \selectlanguage{ngerman}±2.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
31.8 \selectlanguage{ngerman}±5.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
30.6 \selectlanguage{ngerman}±2.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
32.5 \selectlanguage{ngerman}±6.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
32.6 \selectlanguage{ngerman}±3.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.002\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.003\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.005\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note: Data in CON1 group were used to compare to patients with CLBBB and
DDD PM implantation. Data in CON2 group were used to compare to patients
with B-WPW. Data in CON3 group were used to compare to patients with
RVOT-PVC. All data were compared to the corresponding control group.

\textbf{Table 3. LV twist parameters in patients with LBBB patterns and
control subjects.}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
\begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
Groups\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P-value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P-value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P-value\strut
\end{minipage} & \begin{minipage}[t]{0.06\columnwidth}\raggedright\strut
P-value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CON1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CON2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CON3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CLBBB\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
PM\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
B-WPW\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
RVOT-PVC\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CLBBB vs. CON1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
PM vs. CON1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
B-WPW vs. CON2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
RVOT-PVC vs. CON3\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Rot-B(}\selectlanguage{ngerman}°\selectlanguage{english}\textbf{)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-7.1 \selectlanguage{ngerman}±3.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-7.0 \selectlanguage{ngerman}±3.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-5.3 \selectlanguage{ngerman}±3.8\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-7.2 \selectlanguage{ngerman}±3.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-6.0 \selectlanguage{ngerman}±3.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-3.0 \selectlanguage{ngerman}±3.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-0.6 \selectlanguage{ngerman}±4.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.921\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.127\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{TTP-B(\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
48.6 \selectlanguage{ngerman}±11.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
48.9 \selectlanguage{ngerman}±9.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
48.0 \selectlanguage{ngerman}±8.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
59.9 \selectlanguage{ngerman}±12.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
53.1 \selectlanguage{ngerman}±11.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
41.8 \selectlanguage{ngerman}±11.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
40.5 \selectlanguage{ngerman}±18.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.057\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.950\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.004\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.050\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Rot-A(}\selectlanguage{ngerman}°\selectlanguage{english}\textbf{)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
9.6 \selectlanguage{ngerman}±4.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
10.3 \selectlanguage{ngerman}±4.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
9.5 \selectlanguage{ngerman}±3.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
6.0 \selectlanguage{ngerman}±4.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
6.2 \selectlanguage{ngerman}±5.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
7.2 \selectlanguage{ngerman}±6.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
3.9 \selectlanguage{ngerman}±7.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.011\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{TTP-A(\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
47.8 \selectlanguage{ngerman}±10.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
46.2 \selectlanguage{ngerman}±8.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
46.3 \selectlanguage{ngerman}±8.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
62.0 \selectlanguage{ngerman}±17.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
53.5 \selectlanguage{ngerman}±11.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
46.7 \selectlanguage{ngerman}±16.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
38.6 \selectlanguage{ngerman}±16.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.016\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.698\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.878\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.015\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{Twist(}\selectlanguage{ngerman}°\selectlanguage{english}\textbf{)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
16.1 \selectlanguage{ngerman}±5.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
16.9 \selectlanguage{ngerman}±4.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
14.0 \selectlanguage{ngerman}±4.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
10.4 \selectlanguage{ngerman}±5.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
11.2 \selectlanguage{ngerman}±5.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
8.5 \selectlanguage{ngerman}±9.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
4.4 \selectlanguage{ngerman}±9.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{TTP-LV(\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
46.3 \selectlanguage{ngerman}±7.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
46.2 \selectlanguage{ngerman}±7.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
45.2 \selectlanguage{ngerman}±6.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
63.2 \selectlanguage{ngerman}±12.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
54.3 \selectlanguage{ngerman}±9.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
48.0 \selectlanguage{ngerman}±13.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
39.3 \selectlanguage{ngerman}±15.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.478\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.058\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\textbf{TD\textsubscript{A-B}(\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
6.6 \selectlanguage{ngerman}±6.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
7.1 \selectlanguage{ngerman}±8.0\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
7.9 \selectlanguage{ngerman}±8.1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
17.2 \selectlanguage{ngerman}±13.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
10.4 \selectlanguage{ngerman}±8.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
14.0 \selectlanguage{ngerman}±13.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
9.3 \selectlanguage{ngerman}±11.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
<0.001\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.042\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.008\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
0.599\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note: Data in CON1 group were used to compare to patients with CLBBB and
DDD PM implantation. Data in CON2 group were used to compare to patients
with B-WPW. Data in CON3 group were used to compare to patients with
RVOT-PVC. All data were compared to the corresponding control group.

\textbf{Funding} : This study was funded by National Sciences Foundation
of China (grants number: 81771844, 81571691 and 81000618).

\textbf{Conflict of Interest:} All authors have no conflict of interest.

\textbf{Ethical approval:} All procedures performed in studies involving
human participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.

\textbf{Informed consent:} Informed consent was obtained from all
individual participants included in the study.

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