Bundle Branch Block, Right Workup

  • Author: Glenn T Wetzel, MD, PhD; Chief Editor: Steven R Neish, MD, SM   more...
 
Updated: Jul 22, 2010
 

Laboratory Studies

If myocarditis or cardiomyopathy seem to be reflected in the right bundle branch block (RBBB) pattern, consider troponin, creatine kinase (CK), erythrocyte sedimentation rate (ESR), and other laboratory tests for cardiomyopathy (eg, carnitine determination).

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Imaging Studies

Ambulatory ECG (ie, Holter monitoring) may be indicated in postoperative patients who are being periodically monitored or in patients with new right bundle branch block that has a poorly understood etiology and clinical effect.[8]

Echocardiography or myocardial perfusion studies may be indicated if the right bundle branch block is new or if the patient may have coexisting cardiac problems that cannot be adequately assessed with routine ECG. For example, the standard criteria for ventricular hypertrophy or ischemia are relatively unhelpful in a patient with a preexisting intraventricular conduction defect.

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Other Tests

ECG findings in right bundle branch block (RBBB) reflect the underlying pathophysiology.

Transmission of the electrical impulse through the left bundle is normal, resulting in normal depolarization of the septum and left ventricle. This creates the initial R wave in lead V1 and the Q wave in V6.

The electrical impulse in the right bundle branch is delayed or not conducted. Therefore, the right ventricle depolarizes by means of cell-to-cell conduction that spreads from the interventricular septum and left ventricle to the right ventricle. This situation results in the characteristic ECG pattern shown in the image below.

ECGs demonstrate a normal sinus rhythm and a sinusECGs demonstrate a normal sinus rhythm and a sinus rhythm with a right bundle branch block.

Right bundle branch block has been noted to alternate with left bundle branch block and intra-Hisian block.

ECG findings necessary to confirm the diagnosis of right bundle branch block include the following:

For complete right bundle branch block, the duration of the QRS complex is prolonged for the patient's age. Maximum QRS durations are 0.07 seconds for newborns less than 6 days, 0.08 seconds for patients aged 1 week to 7 years, and 0.09 seconds for patients aged 7-15 years.

An rSR' or rR' pattern, with the initial r wave less than the R' or r', may be seen in leads V1-V3R (see the image below). The initial R wave represents septal activation, the S wave represents left ventricular activation, and the R' represents activation of the right ventricle from the septum and left ventricle.

ECG depicts electrophysiologic events of right bunECG depicts electrophysiologic events of right bundle branch block. AV = atrioventricular.

The S wave, which represents right ventricular activation, is wide in leads I and V6 (see the image below).

ECG demonstrates a wide S wave. ECG demonstrates a wide S wave.

The QRS axis may be normal, or right or left axis deviation may be present.

The T wave is almost always inverted in lead V1 and may be inverted in V2. In the other precordial leads and in the limb leads, the T wave is directed opposite to the terminal portion of the QRS complex.

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Procedures

Invasive cardiac catheterization and electrophysiologic testing may be necessary to evaluate patients at risk for heart block or ventricular tachycardia and to document cardiomyopathy, myocarditis, or coexisting hemodynamic abnormalities.

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Contributor Information and Disclosures
Author

Glenn T Wetzel, MD, PhD  Professor of Pediatrics, University of Tennessee College of Medicine; Director, Pediatric Arrhythmia Service, Le Bonheur Children's Medical Center

Glenn T Wetzel, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Heart Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth R Knecht, MD  Fellow, Department of Pediatrics, Division of Pediatric Cardiology, University of Tennessee Health Science Center

Kenneth R Knecht, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Christopher Johnsrude, MD  Associate Professor of Pediatrics, Director of Electrophysiology, University of Louisville School of Medicine; Consulting Staff, Pediatric Cardiology Associates, PSC

Christopher Johnsrude, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Cardiology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Alvin J Chin, MD  Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Cardiology Division, Children's Hospital of Philadelphia

Alvin J Chin, MD, is a member of the following medical societies: American Association for the Advancement of Science, American Heart Association, and Society for Developmental Biology

Disclosure: Nothing to disclose.

Gilbert Z Herzberg, MD  Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center

Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Steven R Neish, MD, SM  Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine

Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Heart Association

Disclosure: Nothing to disclose.

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ECGs demonstrate a normal sinus rhythm and a sinus rhythm with a right bundle branch block.
Anatomy of the penetrating portion of the atrioventricular (AV) bundle.
ECG depicts electrophysiologic events of right bundle branch block. AV = atrioventricular.
Pathophysiology of right bundle branch block. AV = atrioventricular; LV = left ventricular; RV = right ventricular.
ECG depicts electrophysiologic sequence of events that occur in normal cardiac conduction. AV = atrioventricular.
ECG demonstrates a wide S wave.
 
 
 
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