Right bundle branch block

If you get your right bundle branch taken out, your right ventricle depolarises AFTER the left ventricle has finished depolarising. This results in a slightly prolonged QRS (because of the delay in conduction from the left ventricle to the right). Not only that, but when the right ventricle depolarises it can produce an additional QRS complexes, giving rise to this "RSR" pattern.

Of all the branch blocks, this one is the favourite of the college: it has appeared in many past papers.

Features of RBBB:

right bundle branch block

Broad QRS
- M-shaped QRS pattern in V1 – V3 ( "RSR" waves)
- Wide S-wave in lateral leads ( Lead I, V5-6, aVL)

- There will also be T wave inversion in the anterior leads
- There may be an extra R wave in the anterior leads ( R'), or there may just be a broad slurred QRS.
- The depolarization of the right ventricle is delayed
- The left ventricle activates normally: the early part of the QRS remains unchanged

- Axis is unchanged because left ventricular activation is normal.

INCOMPLETE Right Bundle Branch Block
o Normal QRS duration, but RSR pattern in the anterior leads
o This is a normal variant

Causes of Right Bundle Branch Block

- Acute pulmonary embolism
- Right ventricular hypertrophy / cor pulmonale the right bundle is vulnerable to stretching trauma
- Ischaemia
- Myocarditis or cardiomyopathy
- Congenital septal defect

Consequences of Right Bundle Branch Block

- Independent predictor of increased mortality in patients with coronary artery disease
- Dyssynchronous left ventricle: thus, decreased ejection fraction

Management options for Right Bundle Branch Block

- In absence of other conduction abnormalities, with normal ejection fraction: do nothing.
- Isolated RBBB is very rarely a problem.
- If LVEF is poor (<35%) or there is some other heart block, or the patient has episodes of syncope, go with a PERMANENT PACEMAKER.
- These people typically don't respond as well to pacing, as do the LBBBs


From "the ECG made easy", by Hampton (2003), and ECGs shamelessly stolen from Life in The Fastlane without any sort of permission, but in the non-commercial spirit of free education

2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines