Bundlebranchblocks

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Bundlebranchblocks

  1. 1. Bundle Branch BlocksDr.W A P S R Weerarathna
  2. 2. Blood supply• RCA (proximal)  Sinus nodal artery• LAD  Septal branch to proximal RBB and anterior LBB.• LAD (septal) & RCA (terminal)  Posterior fascicle of LBB• PDA  AV nodal branch and bundle of HIS supply
  3. 3. Right Bundle Branch Block (RBBB)• QRS duration ≥ 120ms• rSR’ pattern or notched R wave in V1• Wide S wave in I and V6
  4. 4. Causes• Normal variant in 0.2% of adults.• CAD  Acute anterior MI (occlusion of proximal LAD)• Pulmonary hypertension (COPD)• Acute pulmonary embolism• Congenital heart disease e.g. ASD, Ebstein’s anomaly• Rate dependent RBBB• Rare: Brugada syndrome
  5. 5. Clinical significance• RBBB is commonly seen and is usually benign• RBBB in the setting of an acute MI worsens the prognosis (indicates proximal LAD occlusion)• Presence of RBBB on ECG is not a contraindication for TMT
  6. 6. Right Bundle Branch Block
  7. 7. Left Bundle Branch Block (LBBB)• QRS duration ≥ 120ms• Broad R wave in I and V6• Prominent QS wave in V1• Absence of q waves (including physiologic q waves) in I and V6
  8. 8. Causes• CAD  Acute AWMI (new onset LBBB)• Dilated Cardiomyopathy• Aortic stenosis• Long-standing hypertension• Rate dependent LBBB• RV paced rhythm
  9. 9. Clinical significance• New onset LBBB is an indication for thrombolytic therapy• LBBB in the setting of an acute MI worsens the prognosis• Standard LVH criteria are not valid in presence of LBBB• LBBB may mask signs of myocardial infarction• LBBB on ECG is a contraindication for TMT• Presence of LBBB in heart failure indicates ventricular dyssynchrony
  10. 10. Left Bundle Branch Block
  11. 11. Diagnosis of MI in the presence of LBBB• Sgarbossa criteria: Points• ST segment elevation of ≥1mm 5 concordant with QRS complex• ST depression ≥ 1mm in leads V1-V3 3• ST segment elevation ≥5mm and 2 discordant with QRS complex• Score ≥ indicates Acute MI
  12. 12. Left anterior hemiblock (LAHB)• Left axis deviation (> -30 degrees)• Duration of QRS complex < 120msec• qR morphology in Lead I, aVL• rS morphology in Leads II, III, aVF• ‘q1S3’ pattern• Slurred S waves in left precordial leads
  13. 13. LAHB
  14. 14. LAHB - significance• May be normal variant• Occurs in HTN, Cardiomyopathy• May be seen in acute MI (LAD territory)• Masks old inferior wall MI by abolishing the diagnostic Q-waves in II, III, and aVF LAHB is more common than LPHB
  15. 15. Left Posterior hemiblock• The duration of the QRS complex axis is normal (<120msec)• QRS axis is ≥ +120° (RAD)• Prominent Q wave in leads II, III, and aVF• rS complexes in Leads I, aVL• ‘S1Q3’ pattern
  16. 16. LPHB
  17. 17. LPHB – significance• LPHB may mimic old IWMI due to Q waves in II, III, aVF• LPHB in the setting of Anterior MI indicates extensive damage to the conduction system and poor prognosis• Other causes of RVH are to be excluded before diagnosing LPHB

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