Rbbb final

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  • BBB widens the QRS (120ms or more).
    This widening is due to the fact that the ventricles are forced to contract sequentially, thus requiring more time.
    Other conditions widen the QRS; a common one would be ventricular rhythms either paced or spontaneous.
    A differentiating factor between BBB and ventricular rhythms would be the presence of an underlying supraventricular rhythm.
    Therefore, when a QRS of 120ms or more is produced by a supraventricular rhythm, think BBB.
    This rule applies in all leads.
  • The “classic” pattern for RBBB in V1 is an RSR.
  • Example 1
    underlying rhythm sinus
    QRS width 160ms
    Example 2
    underlying rhythm sinus
    QRS width 120ms
  • Have the participants review these four examples of V1 in the course guide and determine if the BBB is LBBB or RBBB.
  • Rbbb final

    1. 1. Right Bundle Branch Block Dr. Muhammad Imran Janjua HO- MU 1
    2. 2. The Heart
    3. 3. Anatomy Review • Anatomy – – – – SA Node AV Node Bundle of His Left Bundle Branch • Anterior fascicle • Posterior fascicle – Right Bundle Branch – Purkinje Fibres
    4. 4. Conducting System
    5. 5. Normal Ventricular Conduction • Normal Conduction – fibers of LBB begin conduction – impulse travels across inter ventricular septum from left to right • towards + electrode creates small r wave – travels across ventricles causing depolarization of both simultaneously • LV contributes most to complex – impulse travels away from + electrode creates primarily negative complex
    6. 6. RBBB Right bundle branch block (RBBB) results from a defect in the heart's electrical conduction system. There is a delay in or failure of transmission of electrical impulses down the right bundle of the heart. As a result, the right ventricle depolarizes by means of cell-to-cell conduction. These impulses spread more slowly than usual from the inter ventricular septum to the right ventricle. This delay in conduction results in the characteristic ECG pattern which is a wide and notched QRS. Although conduction down the right bundle is delayed, conduction down the left bundle is normal. As result, the inter ventricular septum and left ventricle depolarize in the normal fashion
    7. 7. RBBB
    8. 8. RBBB • The incidence increases with age 1. Below age 30 the incidence is 1.3 per 1000 2. Between 30 and 44 it ranges from 2.0 to 2.9 per 1000
    9. 9. Differential Diagnosis of RBBB • • • • • • • Acute pulmonary embolism Atrial septal defect Cardiomyopathy Cor Pulmonale Coronary Heart Disease Myocardial Infarction Myocarditis
    10. 10. RBBB • Rigt Bundle Branch Block 1.Complete RBBB 2.Incomplete RBBB
    11. 11. Causes Of RBBB 1.After repair of the VSD 2.After right ventriculotomy 3.Right ventricular hypertrophy 4.Increase incidence of RBBB among population at high altitude 5.Ebstein’s anomaly 6.Large ASD (secundum type) or AV cushion defect 7.Brugada Syndrome 8.Trauma
    12. 12. Causes of Incomplete RBBB 1.Atrial septal defect (RAD in secundum or sinus venosus type, LAD with ostium primum type) 2.Ebstein’s anomaly 3.Right ventricular dysplasia 4.Congenital absence or atrophy of the bundle branch 5.After CABG and in transplanted hearts 6.Brugada Syndrome
    13. 13. RBBB: Examination Findings • Right bundle branch block is associated with a persistently split second heart sound with normal respiratory variation in the splitting interval.
    14. 14. RBBB: Lab Evaluation • If there is a history of blunt trauma or any symptoms to suggest polymyositis then troponin, creatine kinase (CK) and an echocardiogram should be obtained.
    15. 15. Anatomic locations of RBBB 1. Proximal, or central, RBBB: block is located just distal to the bundle of His 2. Interruption between the proximal and distal aspects of the right bundle branch 3. Distal RBBB
    16. 16. RBBB • The diagnostic criteria include: • 1.QRS duration is >/- 120 ms • 2.An rsr’,rsR’ or rSR’ pattern in lead V1 or V2 and occasionally a wide and notched R wave. • 3.Reciprocal changes in V5,V6,I and AVL
    17. 17. RBBB Recognition • Fundamental Criteria – Wide QRS • > 100 ms (or, 0.10 sec) – Supraventricular rhythm
    18. 18. RBBB • Criteria for incomplete RBBB are the same as for complete RBBB except that the QRS duration is < 120 ms
    19. 19. RBBB • RBBB in V1 – no change in initial impulse travel • small r wave – impulse depolarizes LV by itself since RBBB – RV depolarized by impulse thru muscle • it now contributes to complex – travels toward + electrode creating positive deflection R-S-R´
    20. 20. RBBB Recognition
    21. 21. RBBB Recognition Practice
    22. 22. RBBB ‘M’ pattern
    23. 23. RBBB
    24. 24. RBBB: Treatment • In general treatment for right bundle branch block is not necessary. • These patients need not limit their activity. • If the RBBB progresses to heart block, further electrophysiologic testing may be necessary.
    25. 25. RBBB: Treatment • Those patients who develop right bundle branch block after surgery should undergo EKG testing each year to evaluate for interval changes. • Particular care should be taken to observe for the development of sinus bradycardia, supraventricular or ventricular ectopy.
    26. 26. RBBB Thank You

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