Chapter 13

Bundle Branch Blocks

and Hemiblocks
 Chapter 13
Normal Pathway of an Impulse

• Impulses generated by
pacemakers in atria or AV
node are normally conducted
down the bundle branches
• Innervate myocardium in an
organized fashion
.
• There are two bundle
branches: right and left.
• The left bundle further
subdivides into the left
anterior and left posterior
fascicles.
 Chapter 13
Blocked Bundle Branch
• In a blocked bundle, the impulse cannot proceed through
the normal conduction system.
• Instead, it travels by direct cell  to  cell 
transmission.
• This is a slow and chaotic way to innervate the
myocardium.
• This accounts for the wide, bizarre complex in PVC or
other aberrantly conducted beat.
 Chapter 13
Right Bundle Branch Block
• With a blocked right bundle impulse to
part of interventricular septum and RV
delayed because of cell  to  cell
depolarization from LV to RV
• Slow impulse causes slower
depolarization time.
– Shows on ECG in QRS interval
≥ 0.12 second

In right precordial leads of V1 and V2,

it develops as RSR′ complex.
 Chapter 13
RBBB’s Effect on the ECG
• RSR′ pattern in lead V1,
• Late innervation of the septum
and RV in RBBB creates a new, with R′ taller than R
slower vector, unopposed by
vectors 1, 2, and 3 in left ventricle.
• New R prime wave appears in
right precordial leads V1 and V2.
• Deep slurred S wave seen in
leads V6, and I (leads that face
the LV)
• S wave is slurred because of slow
transmission of vector.
• Slurring of the S wave is the
most important criterion for
diagnosing RBBB.
 Criteria for Chapter 13
Diagnosing RBBB
1) QRS ≥ 0.12 second

2) Slurred (prolonged) S wave in leads I and V6

3) Positive RSR′ complex in V1 “bunny ears”

 ECG 13-1 Chapter 13
This is a classic example of RBBB.
When you look at leads V1 and V6, you see the classic slurred S wave with
the slow downstroke and upstroke.
There is also a classic rSR′ complex that is typical of the rabbit-ear pattern.
.
 ECG 13-2 Chapter 13
This is an alternative pattern for RBBB
The slurred S wave is obvious, but the complexes in lead V1 are not
as clear. They really form an rsR′R″ pattern.
There is a tiny rs complex at the beginning.
There is an R′ wave that progresses to the next peak (tallest)—the R″.
There is no S wave between the two

<Insert ECG 13-2>

 Chapter 13
Change in Morphology if there has been a
Remote Anteroseptal MI: The QR′ Wave in
RBBB
• QR′ or qR′ wave occurs when
the ECG shows characteristic
changes of anteroseptal
myocardial infarction (ASMI).
• A Q wave takes the place of
the R wave, next positive wave
is an R′ wave; hence QR′.
• The floppy ear negative “Q”
wave is “dead” representing
the infarcted area
RBBB in presence of MIQR’ wave Case Study: Subacute AnteroSeptal
STEMI, With Persistent ST elevation & Upright T-waves
Chapter 13
A man in his 60's presented after 4 days of chest pain, with some increase of pain on the day of
presentation. 
Exact pain history was difficult to ascertain.  There was some SOB. 
He had walked into the ED (did not use EMS). He was in no distress and vital signs were normal.  
There is atrial fibrillation at a rate of 95.  There is Right Bundle Branch Block with a QR particularly noted in
V1-V3 (no rSR', because there is an initial Q-wave; this is diagnostic of infarction in the anterior wall and
septum).  The Q-waves extend to V5 and are very wide (80 ms in V2).  There are also inferior Q-waves which
can mimic a left anterior fascicular block, as they result in left axis deviation.  There is rather massive ST
elevation, and this is not only anterior but inferior wall MI     
ECG 13-4 Chapter 13
This is a qRR′ complex in RBBB
S waves in leads I and V6 are consistent
with RBBB.
A qR wave in V1 is a sign of an old or new
infarct in a pt with RBBB.

<Insert ECG 13-4>

Left Bundle Branch BlockChapter 13
Pathology
• Caused by one of two conditions:
Block of left bundle
Block of both fascicles of left bundle
• Depolarization occurs from left to right
by direct cell-to-
cell transmission.
• Left ventricle is so big that
transmission is delayed
ECG
1) QRS 0.12 seconds or greater
2) Gives rise to broad R waves and T waves
3) Complexes are negative in leads V1 and V2
& positive in leads I, V5, and V6.
4) In LBBB, the T wave is always in the opposite
direction of the terminal portion of the QRS
complex = discordance.
(If the T wave travels in the same direction as
the last part of the QRS complex = concordance)
5) May get notching in V6 (Not RBBB- that is in V1)
ECG 13-15 Chapter 13
LBBB
Note: You cannot diagnose LVH in the presence of LBBB
because the QRS complexes are so wide and bizzare you
cannot include the voltage
 Chapter 13
LBBB
 Chapter 13
LBBB
 Chapter 13
LBBB
 Chapter 13
Common Causes of LBBB
• Potential causes:
– Hypertension
– Coronary artery disease (CAD)
– Dilated cardiomyopathy
– Rheumatic heart disease
– Infiltrative diseases of the heart
– Benign or idiopathic causes
• Vast majority due to hypertension, CAD, or both
 Chapter 13
Summary of Bundle Branch Blocks
• LBBB: not possible to diagnose LVH or RVH.
– Complexes are conducted aberrantly.
– True sizes of complexes cannot be calculated.
– Most LBBBs have normal axis or left axis.
• RBBB: LVH can be diagnosed by normal criteria.
– RVH cannot be diagnosed.
– Ischemia: Remember concept of concordance.
– Atrial enlargement: Use usual criteria.
 Chapter 13
Wide QRS Complexes
When you see the QRS complexes are 0.12
seconds wide or greater, think of five possibilities:

1. LBBB
2. RBBB
3. IVCD (Intraventricular Conduction Delay) A QRS
complex 0.12 seconds wide or greater that does NOT
have all characteristics of LBBB or RBBB
4. PVCs (Premature Ventricular Contractions), or worse,
Ventricular tachycardia
5. Hyperkalemia
ECG 13-21 Chapter 13
Intraventricular Conduction Delay
QRS Wider than 0.12 but does not have RBBB or LBBB
pattern, so it is a nonspecific IVCD
<Insert 13-21>
 Chapter 13
Hemiblocks
• Hemiblock means “half” of
LBBB is blocked after it splits
into left anterior and left
posterior fascicles.
• Blocked left anterior fascicle is
left anterior hemiblock (or left
anterior fascicular block).
• Blocked left posterior fascicle
is left posterior hemiblock (or
left posterior fascicular block).
• Hemiblocks cause ventricles to be
innervated asynchronously and
aberrantly.
• They will alter vectors produced
by the left ventricle.
 Chapter 13
Left Anterior vs. Left Posterior
Fascicles
• Left anterior fascicle:
– Organized, thin bundle of fibers off left bundle
– Gives rise to Purkinje fibers
– These then innervate anterior and lateral walls of LV
• Left posterior fascicle:
– Originates from left bundle
– Not organized into tight fascicle—disperse loosely and fan out
– Origin of fibers that innervate inferior and posterior walls of
left ventricle
 Chapter 13
Left Anterior Fascicular Block (Hemiblock) Left Axis Deviation
Left Posterior Fascicular Block (Hemiblock) Right Axis Deviation

Left Posterior
fascicle
Right
bundle
branch

Left Anterior
Fascicle
 Left Anterior Chapter 13
Hemiblock
• When left anterior fascicle is blocked:
– Depolarization of left ventricle has to progress from
interventricular septum, inferior wall, and posterior wall toward
anterior and lateral walls
– Gives rise to unopposed vector pointed superior and leftward
• Changes net axis of ventricles
toward left, producing left axis
deviation
• Electrical axis of ventricles found
in left quadrant of hexaxial system,
between –30° and –90 °
 ECG 13-26 Chapter 13
Left Anterior Hemiblock
Left axis deviation may have been caused by a remote anteroseptal MI- has
poor R wave progression with QS complex in V1, tiny R wave in V2, and QRS
should have been isoelectric by V3. CAD could have caused ischemia or
infarcted left anterior fascicle resulting in partial LBBB or hemiblock. LAD
because II, III, aVF negative. If aVR considered isoelectric 150-90 =60, or
minus 60 in the left axis deviation quadrant. It is NOT hemiblock if there is LVH
as the cause of the LAD.
 Left Posterior Chapter 13
Hemiblock
• Rare because:
– Left posterior fascicle is difficult to block; fibers are not organized as a
discrete bundle
– Lesion that could cause this type of block would have to be very large
• Criteria for Right Axis Deviation
1. Axis of 90 to 180 °in right quadrant
2. s wave in lead I (Makes Lead I negative and heart vectors point to right)
and q wave in lead III
3. Exclusion of RAE and/or RVH
(this assumes it is fascicular disease causing
the RAD, not some other disease )
 Chapter 13
Left Posterior Hemiblock
Bifascicular Blocks Chapter 13
Combination of RBBB & LPH Combination of RBBB & LAH

– RBBB Rabbit ears pattern in V1 • Common presentation on

– Delayed QRS complex of 0.12 ECGs:
seconds or greater – RBBB Rabbit ears pattern
– Right axis deviation in V1
– Delayed QRS complex of
• RBBB with LPH is not a very
0.12 seconds or greater
stable pattern; it deteriorates
into complete heart block in – Left axis deviation
many cases, especially in the
setting of acute AMI, because it
takes only a small amount of
additional damage to injure the
left anterior fascicle
 ECG 13-32 Chapter 13
Bifascicular Block
RBBB and Left Anterior Hemiblock (Left Axis Deviation)
Usually very stable and does not break down into complete heart
block unless patient has an AMI- then this is an indication for
emergent pacemaker placement.