Ventricular Conduction Disturbances

Chapter 7
Bundle Branches

• Normal conduction speed through the bundles is about 0.1 seconds

Bundle Branch Block

• Consider a blocked or slowed branch or bundle

Right Left
 Right Bundle Branch Block

First Phase will be Second Phase - Third Phase -

normal Normal ?

After the left ventricle has completely depolarized, the right ventricle continues to depolarize
 Right Bundle Branch Block
1. 2. 3.
1. r wave in V1
q wave in V6

2. S wave in V1
R wave in V6

3. R’ wave in V1
S wave in V6
Right Bundle Branch Block Criteria

• V1 or V2 = rSR’ - “M” or rabbit ear shape

• V5 or V6 = qRS
• Large R waves
• Right chest leads: T wave inversion (“secondary changes”
since they reflect a delay in depolarization not an actual
change in depolarization).
• Complete RBBB: QRS > 0.12 sec.
• Incomplete RBBB: QRS = 0.10 to 0.12 sec.
Right Bundle Branch Block

V1 = rSR’ V6 = qRS
Right Bundle Branch Block

V2 = rSR’ V6 = qRS
Right Bundle Branch Block
• Clinical Significance

• Healthy heart

• Organic heart disease

• atrial septal defect

• pulmonary disease

• valvular lesions

• degenerative changes in conduction system

• chronic coronary artery disease

• pulmonary embolism

• after bypass graft surgery

• Permanent or transient

• RBBB by itself requires no treatment

Left Bundle Branch Block

• RBBB affects mainly the terminal

phase of depolarization

• LBBB affects the early and terminal

phases of depolarization

• Septum is depolarized from right

to left (rather than left to right)

• Depolarization of the left ventricle

takes longer
Left Bundle Branch Block

1. r wave in V1
R wave in V6

2. S wave in V1
R wave in V6
Left Bundle Branch Block

• Loss of septal R in V1 and septal Q

in V6.

• Wide QRS

• Negative in V1

• Positive in V6
Left Bundle Branch Block Criteria

• Wide QRS complex

• V1 = QS (or rS) and may have a “W” shape to it.

• V6 = R or notched R showing a “M” shape or rabbit ears

• Secondary T wave inversion

• Secondary if in lead with tall R waves

• Primary if in right precordial leads

Left Bundle Branch Block
RBBB versus LBBB

?
Left Bundle Branch Block
• Causes

• long standing hypertension

• valvular lesion

• cardiomyopathy

• coronary artery disease

• Precursor

1. Advanced CAD

2. Valvular heart disease

3. Hypertensive heart disease

4. Cardiomyopathy
Rate-Related (Exercise-Induced) Bundle Branch
Blocks

• Ischemia or other factors during exercise may produce BBB not seen at rest

• Rate-limited bundle branch block

• Exercise induced bundle branch block

Incomplete Bundle Branch Blocks

• RBBB or LBBB where QRS is between .10 and .12 with same QRS features

• Incomplete RBBB normal variant

• Incomplete LBBB a progression of LVH

Intraventricular Delay or Intraventricular Conduction
Defect

General term
for wide QRS
complexes that
are not typical
of RBBB or
LBBB
Pacemaker Pattern
Pacemaker Patterns
Trifascicular Conduction System
 Tri-fascicular Conduction System

• Right bundle

• Left anterior (superior) fascicle

• Left posterior (inferior) fascicle

• Fascicular block (or hemiblock) = a

block in either the LAF or LPF.
Fascicular Blocks

• Fascicular blocks only slightly prolongs the QRS.

• Fascicular blocks cause axis deviation as do infarcts and hypertrophy.

• Left or right axis deviation without signs of infarct or hypertrophy are fascicular
blocks.
Left Anterior Fascicular Block

• Limb leads

• QRS less width less than 0.12 sec.

• QRS axis = Left axis deviation (-45° or more)

• if S wave in aVF is greater than R wave in lead I

• small Q wave in lead I, aVL, or V6

Left Posterior Fascicular Block
• Right axis deviation (QRS axis +120° or more)

• S wave in lead I and a Q wave in lead III (S1Q3)

• Rare
Bifascicular Block

• Two of the three fascicles are blocked.

• Most common is RBBB with left anterior fascicular block.

Summary

• The last component of the QRS vector will be shifted in the direction of the last part of
the ventricles to be depolarized.

• In other words, the major QRS vector shifts toward the regions of the heart that are
most delayed in being stimulated.

• RBBB: late QRS forces point toward the right ventricle (Rabbit ears, M shape in V1)

• LBBB: late QRS forces point toward the left ventricle (negative in V1 and R or
notched R in V6)

• LAFB: late QRS forces point in a leftward and superior direction (LAD with deep S
wave in aVF ).
Hypertrophy In The Presence of Bundle Branch Block

• RVH and RBBB

• RAD is typically seen; also look for RAE and its peaked P waves.

• RBBB with RAD indicates RVH is likely present, too.

• LVH and RBB

• usual criteria can be used but also look for LAE