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| Image = Right bundle branch block ECG characteristics.png| | | Image = Right bundle branch block ECG characteristics.png| |
| Caption = ECG characteristics of a typical RBBB showing wide QRS complexes with a terminal R wave in lead V1 and slurred S wave in lead V6.| | | Caption = ECG characteristics of a typical RBBB showing wide QRS complexes with a terminal R wave in lead V1 and slurred S wave in lead V6.| |
| DiseasesDB = 11620 |
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| ICD10 = {{ICD10|I|45|1|i|30}} |
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| }} | | }} |
| {{SI}} | | {{Right bundle branch block}} |
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| {{CMG}} '''Associate Editor-In-Chief:''' {{CZ}}
| | '''For patient information click [[Heart block (patient information)|here]]''' |
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| {{SK}} RBBB | | {{CMG}}; {{AE}} {{CZ}}; {{AN}}; {{RT}} |
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| ==Overview==
| | {{SK}} RBBB; bundle branch block right; rt bundle branch block |
| '''Right bundle branch block (RBBB)''' results from a defect in the heart's electrical conduction system. There is a delay or failure of transmission of electrical impulses down the right bundle of the heart. As a result, the right ventricle depolarizes by an alternate mechanism. This is by means of cell-to-cell conduction. These cell to cell conduction impulses spread more slowly than usual from the interventricular septum to the [[left ventricle]] and 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 a result, the interventricular septum and [[left ventricle]] depolarize in the normal fashion.
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| ==Pathophysiology== | | ==[[Right bundle branch block overview|Overview]]== |
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| Three types of [[RBBB]] have been identified based upon electrophysiologic studies.
| | ==[[Right bundle branch block historical perspective|Historical Perspective]]== |
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| In each of the three types of RBBB, the surface ECG pattern remains the same.
| | ==[[Right bundle branch block classification|Classification]]== |
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| '''1. Proximal, or central, RBBB:'''
| | ==[[Right bundle branch block pathophysiology|Pathophysiology]]== |
| This type of conduction defect occurs when the conduction block is located just distal to the bundle of His in the superior aspect of the right bundle branch. This type of block occurs when the proximal bundle is injured during surgery for an inlet or membranous [[ventricular septal defect]] ([[VSD]]).
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| '''2. Interruption between the proximal and distal aspects of the right bundle branch:'''
| | ==[[Right bundle branch block causes|Causes]]== |
| This type of right bundle branch block occurs when the impulse is interrupted between the proximal and distal aspects of the right bundle branch. This type of bright bundle branch block is most commonly observed after surgical division of the moderator band.
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| '''3. Distal RBBB:'''
| | ==[[Right bundle branch block differential diagnosis|Differentiating Right bundle branch block from other Diseases]]== |
| This form is observed when distal ramifications of the right bundle are disrupted during right ventriculotomy or resection of muscle bundles in the right ventricular outflow tract.
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| ===Genetics === | | ==[[Right bundle branch block epidemiology and demographics|Epidemiology and Demographics]]== |
| There can be familial cases of [[right bundle branch block]] such as that observed in 4 Lebanese families and the abnormality was mapped to chromosome 19.
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| ===Associated syndromes=== | | ==[[Right bundle branch block risk factors|Risk Factors]]== |
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| *[[Duchenne muscular dystrophy]]
| | ==[[Right bundle branch block natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| *[[Myotonic dystrophy]]. Other ECG findings include [[first-degree AV block]], [[left anterior fascicular block]], and intraventricular conduction delay. Patients may have arrhythmias and/or [[Stokes-Adams attacks]].
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| *[[Kearns-Sayre Syndrome]]
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| ===Pseudo Right Bundle Branch Block=== | |
| [[Brugada syndrome]]: This syndrome is due to a channelopathy mediated by the SCN5A gene. It is important to note that the RBBB pattern seen in patients with this syndrome is not actually RBBB but is instead due to a repolarization abnormality. It is for this reason that the RBBB like pattern in Brugada syndrome is referred to as a 'pseudo right bundle branch block.' In this syndrome, the ECG shows ST-segment elevation in leads V1-V3. [[Cocaine]] consumption and / or the use of the antiarrhythmic [[propafenone]] may unmask the ECG findings of [[Brugada syndrome]]. | |
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| ==Causes==
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| *Surgery for correction of congenital heart disease is the most common cause of [[RBBB]] among children any United States. This includes surgery for repair of an isolated [[VSD]] or another [[congenital heart disease]] that includes a [[VSD]] (eg, double-chambered right ventricle, AV canal defect, or [[tetralogy of Fallot]]). The incidence of [[RBBB]] varies and ranges from 25-81% after repair of a VSD to 60-100% after repair of [[tetralogy of Fallot]]. The risk of [[RBBB]] after surgery varies depending upon the proximity of the [[VSD]] to the His-Purkinje system.
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| *Blunt [[trauma]]
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| *[[Polymyositis]]
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| *[[Premature atrial contraction]]s or supraventricular tachycardia may cause a transient form up right bundle branch block. This occurs when a premature impulse is conducted from the AV node to the His bundle while the right bundle branch remains in its refractory period, but the left bundle is not. As a result, conduction down the right bundle branch is delayed or blocked.
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| *Prenatal exposure to each one HIV type 1 may cause right anterior hemiblock.
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| * Familial
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| ==Differential Diagnosis==
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| * [[Pulmonary Embolism|Acute pulmonary embolism]]
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| * [[Atrial septal defect]]
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| * [[Ddx:Cardiomyopathy|Cardiomyopathy]]
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| * [[Cor Pulmonale]]
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| * [[Coronary Heart Disease]]
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| * [[Lenegre's Disease]]
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| * [[Lev's Disease]]
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| * [[STEMI|Myocardial Infarction]]
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| * [[Myocarditis]]
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| ==Epidemiology and Demographics==
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| ===Age===
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| The [[prevalence]] of RBBB increases with age.
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| ==Natural History, Complications and Prognosis==
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| In general, the natural history of right bundle branch block benign. Right bundle branch block can be associated with poor prognosis in the following scenarios:
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| #[[Kearns Sayre syndrome]]: again, if right bundle branch block is present than [[sudden death]] may occur.
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| #[[Tetralogy of Fallot]]: if right bundle branch block is present with a markedly prolonged [[QRS]] (< 180 ms), then the patient may be at risk for ventricular [[arrhythmias]] and [[sudden death]].
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| If right bundle branch block is due to surgery then there are generally no acute [[hemodynamic]] consequences. The subsequent courses are also benign. An exception is if there is substantial injury to the His-Purkinje system in which case [[left anterior hemiblock]] or [[first-degree AV block]] may be present. [[Pulmonary arterial line]] placement <ref name="pmid3675104">{{cite journal |author=Morris D, Mulvihill D, Lew WY |title=Risk of developing complete heart block during bedside pulmonary artery catheterization in patients with left bundle-branch block |journal=[[Archives of Internal Medicine]] |volume=147 |issue=11 |pages=2005–10 |year=1987 |month=November |pmid=3675104 |doi= |url=http://archinte.jamanetwork.com/article.aspx?volume=147&page=2005 |issn= |accessdate=2012-10-17}}</ref> in a patient with LBBB can result in a [[complete heart block]] if the right bundle branch is traumatized during the process.
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| There are familial cases of right bundle branch block, which are benign.
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| ==Diagnosis== | | ==Diagnosis== |
| === Physical Examination ===
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| ====Heart====
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| Right bundle branch block is associated with a persistently split second heart sound with normal respiratory variation in the splitting interval.
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| ===Laboratory Findings ===
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| 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.
| | [[Right bundle branch block history and symptoms|History and Symptoms ]] | [[ Right bundle branch block physical examination|Physical Examination]] | [[Right bundle branch block laboratory findings|Laboratory Findings]] | [[Right bundle branch block electrocardiogram|Electrocardiogram]] | [[Right bundle branch block EKG examples|EKG Examples]] | [[Right bundle branch block echocardiography|Echocardiography]] | [[Right bundle branch block other imaging findings|Other Imaging Findings]] | [[Right bundle branch block other diagnostic studies|Other Diagnostic Studies]] |
| ===Electrocardiogram===
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| * The heart rhythm must be supraventricular in origin
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| * The QRS axis can be either normal, or right or left axis deviation may be present.
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| * The QRS duration must be = or > 120 ms
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| ** For complete RBBB, the patient's age must be taken into account to determine if the duration of the QRS complex is prolonged for the patient's age.
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| ***Maximum QRS durations are 0.07 s for newborns <6 days, 0.08 s for patients aged 1 week to 7 years, and 0.09 s for patients aged 7-15 years.
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| * There should be a terminal R wave in lead V1-V3R (e.g., R, rR', rsR', rSR' or qR')
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| ** This pattern is present because 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.
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| * There should be a slurred S wave in leads I and V6. This represent left ventricular activation.
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| ** Because transmission of the electrical impulse through the left bundle is normal, this results in normal depolarization of the septum and the left ventricle. As a result, there is an initial R wave in lead I and V1 and the Q wave in V6.
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| The T wave should be deflected opposite the terminal deflection of the QRS complex. This is known as appropriate T wave discordance with bundle branch block. A concordant T wave may suggest [[ischemia]] or [[myocardial infarction]].
| | ==Treatment== |
| | [[Right bundle branch block medical therapy|Medical Therapy]] | [[Right bundle branch block surgery |Surgery]] | [[Right bundle branch block primary prevention|Primary Prevention]] | [[Right bundle branch block secondary prevention|Secondary Prevention]] | [[Right bundle branch block cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Right bundle branch block future or investigational therapies|Future or Investigational Therapies]] |
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| | ==Case Studies== |
| | | [[Right bundle branch block case study one|Case #1]] |
| Below is an electrocardiogram showing the main characteristics of right bundle branch block on lead V1.
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| [[File:Right bundle branch block 3.png|center|300px]]
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| Copyleft images obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:RBBB.png
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| ===EKG Examples===
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| The [[EKG]] below shows left axis deviation with rSR' pattern (M pattern) in leads [[Electrocardiogram#Precordial|V1]] and [[Electrocardiogram#Precordial|V2]] depicting a right bundle branch block. The EKG shows [[sinus rhythm]]. There are [[wide QRS complexes]] (>120ms) throughout the [[precordium]]. There are small [[R wave|R waves]] in the inferior leads.
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| [[File:Right bundle branch block 2.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E22.jpg
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| The EKG below is from an elderly woman who had previously undergone [[surgery]] for recurrent [[ventricular tachycardia]]. She was being treated with Tambacor and [[metoprolol]]. The EKG shows [[sinus rhythm]] with an sRS' pattern seen in leads [[Electrocardiogram#Limb|I]], [[Electrocardiogram#Precordial|V2]], and [[Electrocardiogram#Precordial|V3]] and a wide QRS of 159ms consistent with a RBBB. There is also a [[right axis deviation]] suggesting a right posterior hemi-block. The [[poor R wave progression]] suggests previous anterior [[MI]].
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| [[Image:Right bundle branch block.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E29.jpg
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| The EKG below is a recording from an older man in the [[surgical intensive care unit]]. He was recovering from a [[motor vehicle accident]] where he sustained a [[chest injury]] from his seat belt. The rhythm is [[sinus rhythm]]. There is an [[RSR']] pattern in lead [[Electrocardiogram#Precordial|V1]] depicting a right bundle branch block.
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| [[Image:Right bundle branch block 1.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E342.jpg
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| The EKG below shows an rsr' pattern in leads [[Electrocardiogram#Precordial|V1]], [[Electrocardiogram#Precordial|V2]], and [[Electrocardiogram#Precordial|V3]] depicting a right bundle branch block with [[left axis deviation]].
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| [[File:Right bundle branch block 4.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:ECG_RBTB_LAtrD.jpg
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| The EKG below shows an RSR' pattern in leads [[Electrocardiogram#Precordial|V2]] and [[Electrocardiogram#Precordial|V3]] depicting a right bundle branch block with [[QRS axis and voltage#Left Axis Deviation (-30 to -90)|left axis deviation.]]
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| [[File:Right bundle branch block 5.png|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an RSR' pattern in leads [[Electrocardiogram#Precordial|V1]], [[Electrocardiogram#Precordial|V2]], [[Electrocardiogram#Precordial|V3]], and [[Electrocardiogram#Augmented lead|aVR]] depicting a right bundle branch block.
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| [[File:Right bundle branch block 6 .jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an rSR' pattern in leads [[Electrocardiogram#Limb|III]], [[Electrocardiogram#Augmented lead|aVR]], [[Electrocardiogram#Augmented lead|aVF]], [[Electrocardiogram#Precordial|V1]], [[Electrocardiogram#Precordial|V2]], and [[Electrocardiogram#Precordial|V3]] depicting a right bundle branch block.
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| [[File:Right bundle branch block 7 .jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an RSR' pattern in leads [[Electrocardiogram#Precordial|V1]] and [[Electrocardiogram#Precordial|V2]], and a qRs pattern in [[Electrocardiogram#Precordial|V6]]. There is slurring of the [[S wave]] in leads [[Electrocardiogram#Limb|I]] and [[Electrocardiogram#Precordial|V6]]. All these patterns suggest right bundle branch block.
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| [[File:Right bundle branch block 8 .jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an rSR' pattern in leads [[Electrocardiogram#Limb|III]] and [[Electrocardiogram#Precordial|V1]]. There is slurring of the [[S wave]] in leads [[Electrocardiogram#Limb|I]] and [[Electrocardiogram#Precordial|V6]]. These findings are consistent with right bundle branch block.
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| [[File:Right bundle branch block 9 .jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an RSR' pattern in lead [[Electrocardiogram#Precordial|V1]], an RSr' pattern in lead [[Electrocardiogram#Precordial|V2]], and [[wide QRS complexes]] in leads [[Electrocardiogram#Precordial|V1]] and [[Electrocardiogram#Precordial|V2]] depicting a right bundle branch block. There is also [[PR prolongation]] which is constant indicating [[first degree heart block]].
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| [[File:Right bundle branch block 11 .jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an RSR' pattern in leads [[Electrocardiogram#Precordial|V1]] and [[Electrocardiogram#Precordial|V2]] indicating a right bundle branch block. [[Tall P waves]] seen in leads [[Electrocardiogram#Limb|II]] and [[Electrocardiogram#Limb|III]] indicate [[right atrial enlargement]].
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| [[File:Right bundle branch block 12 .jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an RSR' pattern in lead [[Electrocardiogram#Precordial|V2]] suggesting right bundle branch block. There is [[ST elevation]] in the [[Electrocardiogram#Precordial|precordial leads]] suggesting [[STEMI]]. [[Heart rate]] is less than 60 suggesting [[bradycardia]]. There is [[left axis deviation]]. In addition, there is [[PR prolongation]] which is constant suggesting [[first degree heart block]].
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| [[File:Right bundle branch block 14.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:RBBB_inf_MI_V4R.jpg
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| The EKG below shows an RSR' pattern in leads [[Electrocardiogram#Precordial|V1]], [[Electrocardiogram#Precordial|V2]], [[Electrocardiogram#Precordial|V3]], [[Electrocardiogram#Precordial|V4]], [[Electrocardiogram#Augmented lead|aVF]], and [[Electrocardiogram#Limb|III]] suggesting right bundle branch block. There is [[left axis deviation]]. In addition, the [[PR prolongation|PR interval is prolonged]] and constant suggesting [[first degree heart block]].
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| [[File:Right bundle branch block 15.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:RBBB_inf_MI_baseline.jpg
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| The EKG below shows an rsR' pattern in leads [[Electrocardiogram#Precordial|V1]] and [[Electrocardiogram#Precordial|V2]] suggesting right bundle branch block. The EKG also shows [[supraventricular tachycardia]].
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| [[File:Right bundle branch block 16.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an rsR' pattern in leads [[Electrocardiogram#Limb|III]] and [[Electrocardiogram#Precordial|V1]], and qR' pattern in leads [[Electrocardiogram#Precordial|V2]] and [[Electrocardiogram#Precordial|V3]] suggesting right bundle branch block. The EKG also shows an old [[Acute MI|anterior MI]] with RBBB.
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| [[File:Right bundle branch block 17.jpg||center|500px]].
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an rsR' pattern in leads [[Electrocardiogram#Limb|III]], [[Electrocardiogram#Limb|aVR]] and [[Electrocardiogram#Precordial|V1]] suggesting right bundle branch block. The EKG also shows an old [[Acute MI|inferior MI]] and [[Acute MI|anterior MI]] with RBBB and [[LAFB]].
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| [[File:Right bundle branch block 18.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an rsR' pattern in lead [[Electrocardiogram#Precordial|V1]] suggesting right bundle branch block. The EKG also shows an old [[Acute MI|inferior MI]] with RBBB
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| [[File:Right bundle branch block 19.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an rsR' pattern in lead [[Electrocardiogram#Precordial|V1]] suggesting RBBB and there is a [[left axis deviation]] suggesting [[LAFB]].
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| [[File:Right bundle branch block 20.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an rsR' pattern in lead [[Electrocardiogram#Precordial|V1]] suggesting RBBB and there is a [[left axis deviation]] suggesting [[LAFB]]. In addition, the [[PR prolongation|PR interval is prolonged]] and constant suggesting [[first degree heart block]].
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| [[File:Right bundle branch block 21.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
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| The EKG below shows an RBBB and [[LAFB]].
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| [[File:Right bundle branch block 22.jpg|center|500px]]
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| Below is an electrocardiogram of a patient with RBBB and [[LAFB]].
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| [[File:Right bundle branch block 23.jpg|center|500px]]
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| Below is an electrocardiogram of a patient with atrial fibrillation with a controlled ventricular rate. The QRS is wide (>120ms) and has a tall R' in V1 and an S wave in V6. There is a left axis deviation. The cardiogram suggests a right bundle branch block and a left anterior hemiblock. The patient has a cardiomyopathy with an ejection fraction of 20%.
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| [[File: Right bundle branch block 24.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E243.jpg
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| The cardiogram below shows sinus rhythm with a normal [[PR interval]] and a prolonged QRS interval (>120ms). There is a conduction abnormality best described as a right bundle branch block due to the rsR' wave in V1. Note the S wave in V6 which is due to the RBBB is smaller than the R wave in V6. The axis of the QRS is difficult to determine, but one usually looks at the first 60 ms. (1 1/2 small squares) to determine the axis with a RBBB. If the axis of the first 60 ms. of the QRS is more than 90 degrees and there is an rS in lead I and a Q in lead III then on would consider a left [[posterior fasicular block]]. This is not the case here.
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| [[File:Right bundle branch block 25.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E196.jpg
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| Below is an electrocardiogram of patient with RBBB
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| [[File:Right bundle branch block 26.jpg|center|500px]]
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| Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/File:E262.jpg
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| == Treatment ==
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| In general, treatment for right bundle branch block is not necessary. These patients need not limit their activity. However, if the RBBB progresses to [[complete heart block]], the patient may be at risk for adverse clinical outcomes. In these patients, further electrophysiologic testing may be necessary. Those patients who develop right bundle branch block after surgery should undergo EKG testing each year to evaluate for interval changes. In particular, care should be taken to observe for the development of [[sinus bradycardia]], supraventricular ectopy, or ventricular ectopy.
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| ==Related Chapters== | | ==Related Chapters== |
| | *[[Electrical conduction system of the heart]] |
| | *[[Electrocardiogram]] (ECG or EKG) |
| | *[[SA node]] |
| | *[[AV node]] |
| | *[[Second degree AV block]] |
| | *[[Third degree AV block]] |
| | *[[Bundle branch block]] |
| | *[[Left bundle branch block]] |
| | *[[Hemiblock]] |
| | *[[Infra-Hisian Block]] |
| | *[[Left anterior fascicular block]] |
| | *[[Left posterior fascicular block]] |
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| * [[Bundle branch block]]
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| * [[Left bundle branch block]]
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| ==References==
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| {{Reflist|2}}
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |
| Line 266: |
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| | [[Category:Arrhythmia]] |
