cardiovascular disorders
Bundle Branch Block and Fascicular Block
Introduction
Bundle branch blockis partial or complete interruption of impulse conduction in a bundle branch;fascicular blockis similar interruption in a hemifascicle of the left bundle. The disorders often coexist. There are usually no symptoms, but presence of either suggests a heart disorder. Diagnosis is by electrocardiography. No specific treatment is indicated. (See also Overview of Arrhythmias .) Conduction blocks (see figure) can be caused by many heart disorders, including intrinsic degeneration without another associated heart disorder. The sinoatrial (sinus) node (1) initiates an electrical impulse that flows through the right and left atria (2), making them contract. When the electrical impulse reaches the atrioventricular node (3), it is delayed slightly. The impulse then travels down the bundle of His (4), which divides into the right bundle branch for the right ventricle (5) and the left bundle branch for the left ventricle (5). The impulse then spreads through the ventricles, making them contract. (RBBB—see figure Right bundle branch block ) can occur in people with no evidence of heart disease. It may also occur with anterior (LBBB—see figure Left bundle branch block ) is associated with a structural heart disorder more often than is RBBB. LBBB usually precludes use of ECG for diagnosis of myocardial infarction. Fascicular blockinvolves the anterior or posterior fascicle of the left bundle branch. Interruption of the left anterior fascicle causes left anterior hemiblock characterized by modest QRS prolongation (<120 millisecond) and a frontal plane QRS axis more negative than−30°(left axis deviation). Left posterior hemiblock is associated with a frontal plane QRS axis more positive than+120°. The associations between hemiblocks and a structural heart disorder are the same as for LBBB. Hemiblocks may coexist with other conduction disturbances: RBBB and left anterior or posterior hemiblock (bifascicular block); and left anterior or posterior hemiblock, RBBB, and 1st-degree atrioventricular (AV) block (incorrectly called trifascicular block; 1st-degree block is usually AV nodal in origin). Trifascicular blockrefers to RBBB with alternating left anterior and left posterior hemiblock or alternating LBBB and RBBB. Presence of bifascicular or trifascicular block after myocardial infarction implies extensive cardiac damage. Bifascicular blocks require no direct treatment unless intermittent 2nd- or third-degree AV block is present. True trifascicular blocks require immediate, then permanent pacing. Nonspecific intraventricular conduction defectsare diagnosed when the QRS complex is prolonged (>120 millisecond), but the QRS pattern is not typical of LBBB or RBBB. The conduction delay may occur beyond the Purkinje fibers and result from slow cell-to-cell myocyte conduction. No specific treatment is indicated. 