Clinical Meaning of Right Bundle Branch Block Pattern on Surface Electrocardiogram in Pacemaker Patients During Right Ventricular Endocardial Pacing

Abstract

Introduction: Right bundle branch block (RBBB) pattern is sometimes observed in right ventricular (RV) endocardial pacing. However, the true mechanism and the clinical meaning of this phenomenon are still unknown.Methods and results: Out of 218 consecutive patients with RV apex endocardial pacing, we studied 30 cases with RBBB pattern and 111 cases with left bundle branch block (LBBB) pattern. No significant differences were found between these 2 groups in age, sex, and pacing mode. However, the percentage of cardiomyopathy patients in the RBBB pattern group was significantly higher than in the LBBB pattern group (36.7% versus 1.8%, p < 0:0001). The left ventricular diastolic dimension (52:2 AE 9:3 mm versus 48:0 AE 5:5 mm, p ¼ 0:05) was bigger and left ventricular ejection fraction (56:2 AE 14:7% versus 66:4 AE 11:6%, p ¼ 0:0003) was lower in the RBBB pattern group. In RBBB pattern group, 11 out of 13 patients with low cardiac function (ejection fraction <50%) showed a wide QRS duration greater than 160 ms in V1 and II leads.Conclusions: RBBB pattern, especially QRS duration wider than 160 ms in V1 and II leads, during RV endocardial pacing may represent left ventricular enlargement and dysfunction. These findings would help assess the cardiac function based on surface 12-lead electrocardiography even in RV pacing. (J Arrhythmia 2009; 25: 16-23)

Right ventricularly paced right bundle–type pattern on ECG: Does this preclude upgrading to biventricular pacing?

“…5 Lastly, severe disease of the right bundle conducting system could result in earlier penetration of the paced electrical impulse into the left ventricular conduction system, with a resultant RBBB pattern on ECG. 6 , 7 …”

“…The more likely explanation is that the tip of the pacing electrode is in the most posterior portion of the right ventricle, on the interventricular septum, relatively far from the chest wall and early precordial chest leads (ie, V 1 –V 3 ). 6 , 7 Klein and colleagues 2 reported that recording an ECG with the V 1 and V 2 leads in the fifth or sixth intercostal space unmasks an LBBB pattern with true apical right ventricular pacing. 2 This maneuver was performed in both patients.…”