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