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Hemiblocks
Take Home Points
www.nottingham.ac.uk/.../cardiac_conduction.gif
Anatomy of the Ventricular
His-purkinje Conduction System
Left bundle branch
Septal fascicle
Septal fascicle
• Initial QRS
remains normal
• Middle portion
of QRS remains
normal
• Terminal QRS
is sluggish and
dominated by
right ventricular
forces
ECG findings in RBBB
Notice the wide RSR' complex in lead V1 and the QRS complex in lead V6. Inverted T waves
in the right precordial leads (in this case V1 to V3) are common with right bundle branch
block and are called secondary T wave inversions.
RBBB
RBBB
RBBB
• Incidence increases with age
• Can occur as a normal variant
• Most common cause is CAD (LAD)
• Other causes include both structural and functional
causes
– Structural: anything causing RV dilatation or hypertrophy,
(acute PE, cor pulmonale, DCM, ect), trauma (right heart
cath, steering wheel, CABG, ablation)
– Functional: rate-related bundle branch block
Differential Diagnosis of RBBB
• Myocardial infarction
• Pulmonary embolism
• Chronic obstructive lung disease/cor pulmonale
• Pulmonary hypertension (primary or secondary)
• Hypertensive heart disease
• Degenerative disease of the conduction system
• Brugada syndrome
• Arrhythmogenic RV dysplasia
• Cardiomyopathy
• Chagas disease
• Congenital heart disease (eg, Ebstein anomaly)
RBBB: prognosis and treatment
• Prognosis depends on underlying etiology
• Worse prognosis for patients with type II second degree
atrioventricular (AV) block or multifascicular block
• Generally good prognosis for patients without
underlying heart disease
• NO treatment necessary for isolated asymptomatic
RBBB
• Pacing may be necessary for symptomatic patients or
those with other AV or multifascicular block
RBBB and MI
Septal fascicle
• Initial QRS
orientation is right-
to-left
• Middle and
terminal QRS
forces are
dominated by the
larger left
ventricular forces
• Slow conduction
causes long QRS
deflection
ECG Findings in LBBB
LPF
Hemiblock / Fascicular block cont.
• A fascicular block occurs when you have impaired
conduction down one division of the LBB
• The block is manifested on EKG as QRS axis deviation
• No / minimal QRS prolongation (0.09 – 0.11 sec)
• Most commonly due to CAD and MI; also
cardiomyopathies
Left Anterior Fascicular Block
• With LAFB the LPF
carries the initial LBB
depolarization inferior, RBB
posterior and to the
LAF
right
• Then the vector shifts
unopposed to the left,
anterior, and
superior
• Common cause of left
axis deviation
LPF
LAFB: ECG findings
LPF
LPFB: ECG findings
• QRS>0.12s
• RSR’ in V1with R’ broad and
slurred
• Wide and slurred S waves in
I, V5, V6
• First half (0.06s) of QRS
having frontal plane axis of
+90° or further to the right
with rS deflection in lead I
and qR waves in II, III, and
aVF
Unknown?