LBBB+RBB
B
Bundle Branch blocks
AV Node
HIS Bundle
RBB
LPF
Purkinje fibers
The Conducting System
Anatomy of the Conduction System
- - - -
Left Bundle
His Bundle Branch
Left Anterior
Fascicle
Right Right Bundle
Left Posterior
Ventricl Branch
Fascicle
e
"RBBB" Right Bundle
Branch Block
Bundle Branch blocks
AV Node
HIS Bundle
RBB
[l LPF
Purkimje fibers
The Conducting
System
• In RBBB, activation of the right ventricle is delayed as depolarisation has to spread across the septum from the left ventricle.
• The left ventricle is activated normally, meaning that the early part of the QRS complex is unchanged.
• The delayed right ventricular activation produces a secondary R wave (R') in the right precordial leads (V1-3) and a wide, slurred
S wave in
• the lateral leads.
Delayed activation of the right ventricle also gives rise to secondary repolarization abnormalities, with ST depression and T wave
inversion in
•
the right precordial leads.
In isolated RBBB the cardiac axis is unchanged, as left ventricular activation proceeds normally via the left bundle branch.
• Broad QRRS =- 120 ms
• RSR' pattern in v-3 (M-shaped' QRRS complex)
• Wide, slurred S wave in the lateral leads (l, aVL, V5-6)
• S T depression and T wave inversion in the right precordial leads (VI-3)
• Sometimes rather than an RSR' pattern in Vl, there may be a broad monophasic R wave or a qR complex.
RBB
B
- - - - - - - - -
Criteria
Secondary repolarizatio
n are usuallyseen in V4.
abnormalities
An "M-shaped" QRS complex V,
in
Prominent S wave in l and
aVL
1
Normal RBBB LBBB
V,
Normal RBBB
II
iY _ V
Typical pattern of T-wave inversion in V1-3 with RBBB
Causes
• Right ventricular hypertrophy / cor pulmonale
• Pulmonary embolus
• lschaemic heart disease
• Rheumatic heart disease
• Myocarditis or cardiomyopathy
• Degenerative disease of the conduction system
• Congenital heart disease (e.g. atrial septal defect)
Causes
• Right ventricular hypertrophy / cor pulmonale
• Pulmonary embolus
• lschaemic heart disease
• Rheumatic heart disease
• Myocarditis or cardiomyopathy
• Degenerative disease of the conduction system
• Congenital heart disease (e.g. atrial septal defect)
-
I''Ir'st-jst'4,k-'kk
Incomplete RBBB
• Incomplete RBBB is defined as an RSR' pattern in vl-3with QRS duration < 120ms
• lt is a n o r m a l v a r i a n t , commonly seen in children (of no clinical significance)
"LBBB" left Bundle
Branch Block "all"
Bundle Branch blocks
AV Node
HIS Bundle
RBB
']
F
LP +
Purkimje fibers
The Conducting
System
'M'
Dominant S wave in VI with broad, notched ('M'-shaped) R wave in
V6
Diagnostic Criteria
• QRS duration of> 120 ms
Dominant S wave in V1
• Broad monophasic R wave in lateral leads (l, aVL. VS5-V6)
• Absence of Q waves in lateral leads (I,V5-V6; small Q waves are still allowed in aVL)
• Prolonged RR wave peak tim e > 60ms in left precordia l lea ds (V5-6)
• Appropriate discordance: the ST segments and T waves always go in the opposite
direction to
• the main vector of the QRS complex
• Poor Rwave progression in the chest leads
Left axis deviation
• 'M'-shaped
• Notched
• Monophasic
• RS co plex
Notched R wave
Mo n o p ha si c R wa v e
Typical appearance of LBBB in V1 with rs complex (tiny
0 ,-./
R deep S wave) and appropriate discordance (ST
wave,
elevatio and upright T
wave)
s
u RS complex
' Widespread secondary
Crite.ria repolarization abnormalities
should also be present:
Q- R·.S-- d.-.-uI r-u!
11t..· ·1.io-n · -~ . 1: ·2-0 ·· Leads I, aVL, V, usually display
a
I .
m · s·
downsloping ST depression
. . .
Broad R wave in I, aVl, V,
and leading into an inverted T
wave.
Leads V,, usually display a deep
Lack of septal q waves in I, and S
V,
wave, with upsloping ST
elevation leading into a
upright and prominent T
wave.
Caus
es
• Aortic sten0sis
• lschemic heart disease
• hypertension
• Dilated cardomyopathy
• Anterior Ml
• Primarydegenerativedisease (fibrosis) of the conducting system
• (Lenegre disease)
• yperkalemia
Digoxin toxicity
LBB
B
n z
v 1 / L
sVR
y r 5I c c -
L i. 4.h +
t
7
j+
n
LI
f
n
Incomplete LBBB
• Incomplete LB3B is diagnosed when typical LB3B morphology is associated with a QRS
duration < 120ms.
-l .. ' l t . - . . . .· •. . .·. ·. .· , , . ·. , - I ' I I '
- . , I I
ru i
u
;
u
j
'
;
,
lc,
' y ,[
- h
r (l ~ [
l ]l~. [ ~ -Ls' L U
7 if
,
"lf [
4
o } J
+
i
l
Incomplete LBBB (QRS
duration110ms)
n
tt v4
v
t
Left Bundle Branch
-
Block
-
i 4 % % - / ' / ' "
-I j : • [ '\ [A ]• [
}'A
I ' , ·
\ $
1 1
.., . .
.
. . .
.
.·
.
.
.
1
11; J r· J , l /'l I_ • , i ~ •
,
~. ,
LeftBundleBranchBlock
t
AF with
L8BB
Right bundle branch block L e f t b u n d l e b r a n c h b l oc k
n n
-v{v
VR
n
-4ls
v,
Left Anterior Fascicular Block
AV Node
HIS Bundle
RBB
']
F
LP +
Purkimje fibers
The Conducting
System
• Left axis deviation (usually between -45and -90degrees)
• Small Qwaves with tall R waves (= 'qR complexes') in leads and
• I aVL
II, Ill, aVF
• Small Rwaves withdeep S waves (= 'rS complexes') in leads
QRS duration normal or slightly prolonged (&0-·10 ms)
ProlongedRRwave peak time in aVL>45ms
• Increased QRS voltage in the limb
leads
• LAD
Left Anterior Fascicular Block
-
t .
d .
M e " f a . w _ ' · , w r ' _ l ,
I
t g r " a d ' l
I 3 ± £ 2e"
=-
i
...
II
--- . • I . • •• 7
f l {' :'
_ . : .
--j
+
=-
I
7
Left Posterior Fascicular Block
AV Node
HIS Bundle
RBB
']
F
LP +
Purkimje fibers
The Conducting
System
Diagnostic C r i t e r i a f o r L P F
• Right axis deviation (> +90 degrees)
Small RR weves with deep Swaves (=rS complexes')in leads land aVl
• SmallQwaves with tall R waves (= 'qR complexes') in leads Il, Ill and aVF
• QRS duration normal or slightly prolonged (&0-110ms)
• Prolonged Rwave peak time in aVF
• Increased QRS voltage in the limb leads
• No evidence of right ventricular hypertrophy
No evidence of any other cause for right axis deviation
, 1PF3ismuchlesscommonthanLAF8, sthe broad bund'e offtres that comprise theleftposterior
fascicle ere relatively resistantto
damage when compared with the slim sing'e tract that makes up the left anteriorascc'e.
• lisextreme'yrereto see lPFBin isolation. ltusu:lly occurs +long with R83 tie contextof a
bfasccularblock.
• Donette temptedto dagnose LP3 untlycu have ruled outmore significant causesof right
axisdeviation:ie. acutePE, ticycic
Left Posterior Fascicular
Block
Biracirular - RBBB LAFB or LPFB
Trifzicular Block Bi fascicular 15
degree AV block
Bifascicular
Block
[[ , _ 1 - - A - A A -
A_./
uR Vt
n. .
•
n w
vi
n ·
- .
•
I
• Right bundle branch block
• Left axis deviation (= left anterior fascicular
block)
First degree V block
