RBBB MORPHOLOGY ARRYTHMIAS

1. DIFFERENTIALS OF
ARRYTHMIAS WITH
RBBB MORPHOLOGY
DR SRIKANTH N

2. RBBB MORPHOLOGY
 Wide QRS complexes with duration more than 120 msec
 V1 : large terminal R’ waves with Rr’ or rsR’ configuration
 Onset of intrinsincoid deflection ( R peak time) > 0.05 sec
 V6 and I , Avl : wide terminal S waves present
 Septal q waves are preserved

3. COMPLETE RBBB

4. RBBB MORHPHOLGY

5. INCOMPLETE RBBB
 QRS COMPLEXES DURATION LESS THAN 120 msec
 V1 rsR’ or Rr’ pattern
 V6 slightly widened S wave
INTERMITTENT RBBB
 RBBB occurs intermittently before it becomes fixed
 Rate related– occurs when the heart rate exceeds a certain level

6. Incomplete RBBB

7. INTERMITTENT RBBB

8. RBBB+LAFB vs RBBB+LPFB
 RBBB in v1 to v6
 Left axis deviation > -30 degree
 lead 2 small r S
 Tall R IN aVL
 RBBB in v1 to v6
 Right axis deviation > 90 degree
 Deep S wave in lead 1
 Tall R in lead iii,aVF

9. RBBB+LAD=BIFACICULAR(RIGHT+LAFB)

10. RBBB+RAD=BIFASCICULAR(RBBB+LPFB)

11. SECONDARY REPOLARISATION vs PRIMARY
REPOLARISATION CHANGES

12. Differentials of arrythmias with RBBB
morphology
 IDIOPATHIC VT
 SVT WITH RBBB MORPHOLOGY
 RATE RELATED RBBB
 ASHMANN PHENOMENON
 SVT WITH ABERRANT CONDUCTION
 MONOMORPHIC VT(LVOT VT)
 TCA OVERDOSE,FLECAINAIDE OVERDOSE
 FOCAL PURKINJE VENTRICULAR ARRYTHMIAS (LEFT PUKINJE SYSTEM)

13. IDIOPATHIC FASCICULAR VT
 10% OF MONOMORHIC VT ARE IDIOPATHIC(absence of structural heart
disease)------out of which 75-90% are RVOT VT,10-25% are FACICULAR
VT.
FASCICULAR VT
LEFT POSTERIOR FASCICULAR VT –RBBB + LAD
LEFT ANTERIOR FASCICULAR VT---RBBB+RAD
UPPER SEPTAL FASCICULAR VT---- RBBB OR ATYPICAL axis

15. ECG INTERPRETATION
 QRS UPTO 120 MSEC
 V1 QRS RSR’ MORPHOLOGY
 LAD -90 DEGREE
 CAPTURE BEATS
 DISSOCIATED P WAVES

18. QUESTION 1

19. QUESTION 2

20. QUESTION 3 , AV DISSOCIATION

21. RBBB MORPHOLGY FAVOURING SVT

22. RBBB MORHOLOGY(SVT)

23. Yoav Michowitz. Circulation: Arrhythmia and Electrophysiology.
Differentiating the QRS Morphology of Posterior Fascicular Ventricular
Tachycardia From Right Bundle Branch Block and Left Anterior
Hemiblock Aberrancy, Volume: 10, Issue: 9, DOI:
(10.1161/CIRCEP.117.005074) © 2017 American Heart Association, Inc.

25. VT WITH RBBB
 RBBB MORPHOLOGY WITH TACHYCARDIA
 WITH QRS DURATION MORE THAN 140 MSEC
 RIGHT AXIS DEVIATION
Left anterior vascicular VT

26. SVT WITH RBBB

27. SVT WITH RBBB PATTERN

28. RATE RELATED BUNDLE BRANCH
BLOCK
 BROAD QRS MORE THAN 120 MSEC AT HIGHER RATE
 AT BUNDLE OF HIS OR RIGHT OR LEFT BUNDLE—INTRINSIC
DISEASE,DRUGS,HYPERKALEMIA

29. RBBB > LBBB

30. RATE RELATED RBBB

31. GOUAUX ASHMAN PHENOMENON
 INTRAVENTRICULAR CONDUCTION SYSTEM ABNORMALITY RESTRICTED
TO HIS PURKINJE SYTEM
 RELATIVELY LONG CYCLE WAS FOLLOWED BY SHORT CYCLE
 BEAT WITH SHORT CYCLE HAS RBBB MORPHOLOGY

32. ASHMANS PHENOMENON

33. ASHMANN

34. SVT WITH ABERRANT CONDUCTION

35. TRICYCLIC ANTIDEPRESSANT
OVERDOSE
 SINUS TACHYCARDIA WITH FIRST DEGREE AV BLOCK
 BROAD QRS
 POSITIVE R’ IN aVR

36. TCA OVERDOSE

37. MONOMORHIC VT

38. ANATOMY

39. Precordial Transition
Lead V1- Location: right anterior chest wall
 Anterior structures (RVOT, PA, ant LVOT
i.e Rt sov)-predominantly negative
deflection (i.e, LBBB pattern)
 More posterior sites (AMC,LV summit
,lateral mitral annulus) -more positive
deflections (RBBB pattern).
Anterior
Posterior
1. Precordial transition
becomes sequentially
earlier
2. LBBB pattern->
RBBB pattern

40. Frontal Plane Horizontal Axis
 Lead I- Location: Left Axilla
 Structures closer to the left axilla-
negative deflection(Right Axis)
 Structures closer to right axilla-
positive deflections (Left axis).
Lead II/aVL: leftward vector.
Lead III/aVR:rightward vector.
1. Less positive/more negative deflection in lead I
2. Taller R wave in lead III than in lead II, and a larger S wave in
lead aVL compared with lead aVR.
Right Left

41. Frontal Plane Vertical Axis
Leads II, III, and aVF:Inferior
location
 Superior structures (close to
OTs)-InferiorAxis
 Inferior structures (closer to
apex)-Superior axis.
Leads aVL and aVR:
Left & Right Superior
location.
Superior
Inferior
1. QS in inferior leads
2. R in superior leads

42. RBBB = MITRAL
ANNULAR,PAPILLARY,FASCICULAR