Intraventricular Conduction

Delays Review
Advanced Diagnostic Medicine
Session 3
Jesse A. Coale, DMin, PA-C
The Intraventricular Pathways
Right Bundle Branch Block
Right Bundle Branch Block

• Criteria
• M-shaped pattern QRS (RSR’) in Lead V1 –V3 or sometimes wide R or qR in V1
• Wide slurred S wave in lateral leads (Lead I, aVL, V5-6)
• QRS duration
• > 0.12 sec is complete
• < 0.12 sec is incomplete
• Associated features
• ST depression and T wave inversion in right precordial leads (V1-3)
 Brugada
Syndrome
Left Bundle Branch Block
Left Bundle Branch Block

• Criteria
• Dominant S wave in V1
• Broad monophasic R wave in lateral leads (Lead I, aVL, V5-6)
• Absence of Q waves in lateral leads (Lead I, V5-6; small Q still allowed in aVL
• Prolonged R wave peak time > 60 ms in left precordial leads (V5-6)
• QRS duration
• > 0.12 sec complete
• < 0.12 sec incomplete
Left Bundle Branch Block

• Associated features
• Appropriate discordance of the ST segments and T wave
• Go in the opposite direction to the main vector of the QRS complex
• Poor R wave progression in the chest leads
• Left axis deviation
• QRS Morphology in the lateral leads can be either:
• M shapped
• Notched
• Monophasic
• RS complex
Left Bundle Branch Block

• A new LBBB – could indicate an underlying heart

disease
• Need to consider evaluation of coronary blood flow
• Traditionally, ischemia/infarction regarded as
uninterpretable in presence of LBBB
• The Sgarbossa Criteria (Modified)
• ST elevation > 1mm and in same direction (concordant)
with QRS – 5 points
• ST depression > 1 mm in Leads V1, V2, or V3 and
concordant– 3 points
• Discordant ST/T ratio < -0.25
Left Bundle Branch Block
Comparison of RBBB and LBBB
Left Anterior Fascicular Block

• The Hint is Left Axis Deviation

Left Anterior Fascicular Block

• Criteria
• Left axis deviation
• Presence of Q wave in Lead I, aVL
• Presence of rS in Lead II
• Small R wave in Lead II, III, aVF
• Tip
• Old inferior MI cannot be diagnosed in the setting of LAFB
 Quick Method
Left Anterior Fascicular 1.
Block Identify LAD
• QRS is up Lead I
• QRS is down Lead aVF
• QRS down Lead II

2. Look at Lead III

• rS complex is present
Left Posterior Fascicular Block

• The Hint is Right Axis Deviation

Left Posterior Fascicular Block

• Criteria
• Right Axis Deviation
• Small Q waves with tall R waves in Leads II, III, aVF
• Small R waves and deep S waves in Leads I, aVL
• QRS duration is normal or only slightly prolonged
• No evidence of RVH, no other causes of RAD
• Tips
• LPFB is much less common than LAFB
• Rare to see LPFB in isolation; usually occurs with RBBB
• DO NOT BE TEMPTED TO DIAGNOSE LPFB UNTIL OTHER CAUSES ARE RULED OUT
• Acute PE, tricyclic OD, lateral MI, RVH