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ECG EKG Bundle Branch Block
ECG EKG Bundle Branch Block
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Passage of current through the heart
The initial signal originates at the sinoatrial node (SAN)
It is conducted through the myocardium of the atria and then passes via the atrio
ventricular node (AVN) to the bundle of His. This bundle then splits into two bundle
branches (left and right)
The left bundle further splits into anterior and posterior fascicles (more on that later)
Conduction continues through the Purkinjie fibres and finally into the ventricular
muscle which contracts in systole which corresponds to the QRS complex
Below we discuss what happens when the conduction system is interrupted. The figure
below gives an overview but we will look at each block in more detail.
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1st degree heart block
1st degree block indicates slowed transmission of electrical activity through the AV node –
therefore giving a prolonged PR interval. It can be a normal variant.
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Mobitz Type 2
In Mobitz type 2 the PR interval is constant. However, there is an occasional non
transmitted beat which may also be seen as 2:1 or 3:1 block – here there are alternate
conducted and non-conducted beats.
The above ECG shows 2:1 block with 2 P-waves for every one QRS
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3rd degree heart block (complete heart block)
In 3rd degree heart blocks the connections between the atria and the ventricles are
completely lost. The atrial rate continues as normal (as seen by regular p-waves).
However, the actual heart rate is slow reflecting a ventricular escape rhythm which is
generated from a focus within the ventricular muscle its self. Each p-wave is not
associated with a QRS complex and the QRS complex is wide reflecting its ventricular
origins.
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Right bundle branch block (RBBB)
RBBB may be a normal variant – especially if the pattern is present but with a
normal QRS duration.
Otherwise it may indicate problems with the right side of the heart.
In RBBB you will see wide complexes with a RSR pattern in V1 and deep S wave in
V6.
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How RBBB works
From first principles RBBB occurs as left ventricular contraction happens just prior
to right ventricular contraction (as the R bundle is not working) where they would
normally contract together.
Remember that the positive deflection is caused by depolarization travelling towards
that lead. Therefore:
Initially there is septal depolarization (left to right) causing a small R wave in
V1 and Q wave in V6
Then LV contraction causes an S wave in V1 and R wave in V6
Then RV contraction causes an R wave in V1 and a deep S wave in V6
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From first principles:
The septum depolarizes from R to L causing a Q wave in V 1 and a R wave in
V6
The R ventricular contraction occurs first causing an R wave in V1 and a S
wave in V6
Then LV contraction causes an S wave in V1 and a further R wave in V6
Fascicular blocks
The left bundle can also be split into anterior and posterior fascicles (as shown in
the figure above) and block can affect either of these.
Anterior fascicular block
If the anterior fascicle is blocked the cardiac axis swings round to the left
causing left axis deviation.
This is known as left anterior hemiblock
It is often caused by LVH
Posterior fascicular block
Uncommonly the left posterior fascicle is exclusively blocked in which case
there is right axis deviation.
Bifascicular block
If the left anterior fascicle (or left posterior fascicle but this is much less
common) and the right bundle are blocked you will see both right bundle
branch block and left axis deviation, this is known as bifascicular block.
This is clinically important as the patient may intermittently go into complete
heart block as they are solely relying on the posterior fascicle for ventricular
contraction.
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This ECG shows bifasicular block
Trifascicular block
If there is bifasicular block with a prolonged pr interval (i.e. first degree block) this is
known as trifasicular block as there is block in 2 fasicles and a delay in the 3rd
As with bifasicular block it should be treated urgently as it may deteriorate into
complete heart block
Click here for medical student OSCE and PACES exam questions
about ECGs
Common ECG questions for medical students, finals, OSCEs and MRCP PACES
…and click here to read about the best way to interpret an ECG
systematically
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