Alternating LBBB with Right Axis Deviation
Report:
Sinus rhythm 93/min
Alternating complete & incomplete left bundle branch block
Axis +95o with complete LBBB
Indeterminate axis with incomplete LBBB
Comment:
The basic LBBB morphology is, as always, best seen in lead V1. In the limb leads, both complete and incomplete LBBB are widely notched and atypical. The incomplete LBBB is, roughly, equiphasic in all 6 frontal plane leads – the indeterminate axis. The complete LBBB is slightly more negative than positive – or, at least, also equiphasic – in lead 1, producing the RAD.
This is the only patient with normal ventricle and LBBB/RAD combination I have seen so far. He presented with distal dissection only, when a normal transœsophageal echo was obtained. Taken to OR to repair the intima, he dissected proximally and the aortic root had to be replaced, with resuspension of the valve. On few occasions he was profoundly hypotensive: this may well be the mechanism of myocardial damage to account for transient LBBB. One usually suspects the surgeon’s fingers in cases like this, but this is unfair.
Subsequently, LV function and the ECG (Fig 33a) normalised.
An example of permanent LBBB and RAD in a patient with congestive cardiomyopathy is shown in Fig 33b.
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