LBBB with Prominent R Wave in V2

Report:

Sinus rhythm

First degree AV block

PR interval 0.24”

Left bundle branch block

Comment:

Prominent narrow R wave in V2, with subsequent diminution (through V5 in this example) is said to be a sign of old anterior infarction with LBBB. In my experience, it is, rather, a sign of congestive cardiomyopathy, like RAD. This patient had an 8.2 cm left ventricle with fractional shortening of 8%, on carvedilol therapy for Class IIIA NYHA heart failure. It is not known if he had an infarction in the past and he was beyond angiography. He also has an LAD –50o. Marked LAD in LBBB is not routinely reportable, but it may imply worse outlook.

Below (Fig 23a) is another example, from a patient with proven primary cardiomyopathy.

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