Alternating bundle branch block is diagnosed when conducted
periods of RBBB and LBBB were noted in a patient on the same or different electrocardiograms Electrocardiographic diagnosis suggesting the presence of bilateral bundle branch disease Poor prognosis associated with complete heart block,syncope and sudden cardiac death Mechanism of alternating bundle branch block
ECG pattern of LBBB occurS
H-V INTERVAL reflects conduction time in distal His bundle and RBB Rate dependent block
RBBB occurs( rate dependent)
H-V interval reflects conduction time of distal His bundle and left bundle Length equivalent to delay in left bundle Maintenance of RBBB once initiated, depend upon the retrograde concealed conduction to the right bundle branch If right bundle recovery occurs is rapid despite concealed conduction , beat to beat alternation in BBB Rate dependent block
If cycle length of spontaneous sinus
rhythm is close to the refractory period of right bundle ---prolonged periods of left and right bundle branch pattern can be seen Non rate dependent block
Incomplete left bundle branch block
with intermittent non rate dependent RBBB H-V interval again reflects distal His bundle and left bundle and lengthened by conduction in left bundle Narrow QRS
DESTRUCTIVE LESION involving the distal His
bundle AND PROXIMAL BUNDLE BRANCH FIGURE B –intermittent LBBB FIGURE C- intermittent RBBB FIGURE D- intermittent block in both bundles and manifestation of paroxysomal heart block Clinical significance
Alternating BBB – WITH SYNCOPE –permanent pacing
Alternating BBB- WITHOUT SYMPTOMS ,WITHOUT NARROW QRS – CLOSE FOLLOW UP Alternating BBB –NARROW QRS- PERMANENT PACEMAKERS Alternating BBB- ACUTE MYOCARDIAL INFARCTION-TEMPRORY PACEMAKER SHOULD BE INSERTED regardless of mechanism and H-V interval