Right Bundle Branch Block-Like Pattern During Uncomplicated Right Ventricular Pacing and the Effect of Pacing Site

Published:December 29, 2015DOI:
      Right bundle branch block (RBBB) configuration is an unexpected finding during right ventricular (RV) pacing that raises the suspicion of inadvertent left ventricular lead positioning. The aim of this study was to evaluate the prevalence of paced RBBB pattern in relation to RV lead location. This is a secondary analysis of a prospective, multicenter study, which randomized implantable cardioverter defibrillator recipients to an apical versus midseptal defibrillator lead positioning. A 12-lead electrocardiogram was recorded during intrinsic rhythm and RV pacing. Paced RBBB–like pattern was defined as positive (>0.05 mV) net amplitude of QRS complex in leads V1 and/or V2. In total, 226 patients (65.6 ± 12.0 years, 20.8% women, 53.1% apical site) were included in the study. The prevalence of paced RBBB pattern in the total population was 15.5%. A significantly lower percentage of patients in the midseptal group demonstrated RBBB-type configuration during RV pacing compared with the apical group (1.9% vs 27.5%, p <0.001). Baseline RBBB, prolonged QRS duration during intrinsic rhythm, and reduced ejection fraction were not associated with increased likelihood of paced RBBB. In the subgroup of patients with RBBB type during pacing, 91.4% of patients had a paced QRS axis from −30° to −90°, whereas 100% of patients displayed a negative QRS vector at lead V3. In conclusion, RBBB configuration is encountered in a considerable percentage of device recipients during uncomplicated RV pacing. Midseptal lead positioning is associated with significantly lower likelihood of paced RBBB pattern compared with apical location.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Barold S.S.
        • Narula O.S.
        • Javier R.P.
        • Linhart J.W.
        • Lister J.W.
        • Samet P.
        Significance of right bundle branch block patterns during pervenous ventricular pacing.
        Br Heart J. 1969; 31: 285-290
        • Mower M.M.
        • Aranaga C.E.
        • Tabatznik B.
        Unusual patterns of conduction produced by pacing stimuli.
        Am Heart J. 1967; 74: 24-28
        • Almehairi M.
        • Enriquez A.
        • Redfearn D.
        • Michael K.
        • Abdollah H.
        • Alfagih A.
        • Nolan R.
        • Baranchuk A.
        • Simpson C.S.
        Right bundle branch block-like pattern during ventricular pacing: a surface electrocardiographic mapping technique to locate the ventricular lead.
        Can J Cardiol. 2015; 31: 1019-1024
        • Okmen E.
        • Erdinler I.
        • Oguz E.
        • Akyol A.
        • Turek O.
        • Cam N.
        • Ulufer T.
        An electrocardiographic algorithm for determining the location of the pacemaker electrode in patients with right bundle branch block configuration during permanent ventricular pacing.
        Angiology. 2006; 57: 623-630
        • Coman J.A.
        • Trohman R.G.
        Incidence and electrocardiographic localization of safe right bundle branch block configurations during permanent ventricular pacing.
        Am J Cardiol. 1995; 76: 781-784
        • Refaat M.
        • Mansour M.
        • Singh J.P.
        • Ruskin J.
        • Heist E.K.
        Electrocardiographic characteristics in right ventricular vs biventricular pacing in patients with paced right bundle-branch block QRS pattern.
        J Electrocardiol. 2011; 44: 289-295
        • Klein H.O.
        • Beker B.
        • Sareli P.
        • DiSegni E.
        • Dean H.
        • Kaplinsky E.
        Unusual QRS morphology associated with trans-venous pacemakers. The pseudo RBBB pattern.
        Chest. 1985; 87: 517-521
        • Wilkoff B.L.
        • Cook J.R.
        • Epstein A.E.
        • Greene H.L.
        • Hallstrom A.P.
        • Hsia H.
        • Kutalek S.P.
        • Sharma A.
        Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) trial.
        JAMA. 2002; 288: 3115-3123
        • Sweeney M.O.
        • Hellkamp A.S.
        • Ellenbogen K.A.
        • Greenspon A.J.
        • Freedman R.A.
        • Lee K.L.
        • Lamas G.A.
        Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction.
        Circulation. 2003; 107: 932-937
        • Shimony A.
        • Eisenberg M.J.
        • Filion K.B.
        • Amit G.
        Beneficial effects of RV non- apical vs. apical pacing: a systematic review and meta-analysis of randomized- controlled trials.
        Europace. 2012; 14: 81-91
        • Kolb C.
        • Tzeis S.
        • Andrikopoulos G.
        • Asbach S.
        • Lemke B.
        • Hansen C.
        • Deisenhofer I.
        • Zrenner B.
        • Birkenhauer F.
        • Vardas P.E.
        Rationale and design of the SPICE study-mid-septal positioning of ventricular ICD electrodes.
        J Interv Card Electrophysiol. 2011; 31: 247-254
        • Kolb C.
        • Solzbach U.
        • Biermann J.
        • Semmler V.
        • Kloppe A.
        • Klein N.
        • Lennerz C.
        • Szendey I.
        • Andrikopoulos G.
        • Tzeis S.
        • Asbach S.
        Safety of mid-septal electrode placement in implantable cardioverter defibrillator recipients – results of the SPICE (septal positioning of ventricular ICD electrodes) study.
        Int J Cardiol. 2014; 174: 713-720
        • Barold S.S.
        • Herweg B.
        Usefulness of the 12-lead electrocardiogram in the follow-up of patients with cardiac resynchronization devices. Part I.
        Cardiol J. 2011; 18: 476-486
        • Andrikopoulos G.
        • Tzeis S.
        • Asbach S.
        • Semmler V.
        • Lennerz C.
        • Solzbach U.
        • Grebmer C.
        • Kloppe A.
        • Klein N.
        • Pastromas S.
        • Biermann J.
        • Kolb C.
        A stepwise electrocardiographic algorithm for differentiation of mid-septal vs. apical right ventricular lead positioning: the SPICE ECG substudy.
        Europace. 2015; 17: 915-920
        • Almehairi M.
        • Ali F.S.
        • Enriquez A.
        • Michael K.
        • Redfearn D.
        • Abdollah H.
        • Simpson C.
        • Chiale P.A.
        • Baranchuk A.
        Electrocardiographic algorithms to predict true right ventricular pacing in the presence of right bundle branch block-like pattern.
        Int J Cardiol. 2014; 172: e403-e405
        • Saksena S.
        Mechanism of an unusual QRS pattern associated with right ventricular pacing.
        Am Heart J. 1983; 105 (Brief communication): 337-339
        • Hemminger E.J.
        • Criley J.M.
        Right ventricular enlargement mimicking electrocardiographic left ventricular pacing.
        J Electrocardiol. 2006; 39: 180-182