Alternating bundle branch block

 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