CASE REPORT

Right bundle branch block pattern in right ventricular permanent pacing

Introduction

An 70 year old woman come to the emergency room with chief complaint of chest pounding
since 2 weeks ago. The patient had undergone a procedure of pace maker implantation 2 weeks
ago. Her ECG showed ventricular pacing with unusual right bundle branch block (RBBB)
configuration (Figure 1).

Objective

Upon suspicion of a possible malpositioned lead in the left ventricle, diagnostic work up was
done to confirm the lead position of the pace maker

Methods

We took another ECG by placing the precordial leads one interspace lower than the standard
position. In Addition, the patient also underwent transthoracic echocardiography and
Fluoroscopic to confirm the lead position of the pace maker.

Result

The ECG taken by placing the precordial leads one interspace lower than standard that
eliminated Right Bundle Branch Block appearance and resulted in the inscription of deep QS
complexes in V1 and V2. Transthoracic echocardiography clearly showed the pacing lead
traversing from the right atrium to the right ventricle and lying in the right ventricular apex.
Fluoroscopic views taken on both directions also revealed right sided and antero-inferiorly
oriented ventricular pacing lead whose tip was positioned infero-apically in the right ventricular
apex

Conclusion

Right Bundle Branch Block pattern during ventricular pacing does not always meant ventricular
pacing due to a malpositioned ventricular lead. Safe uncomplicated right Bundle Branch Block
pattern may be seen with correctly positioned right ventricular leads in the distal septum or
apex. Techniques such as moving the leads V1-2 one interspace lower than standard to identify
the lead placement are proven accurate. Transthoracic echocardiography and Fluoroscopyuseful
can be used as confirmatory techniques to remove any doubt about lead misplacement in pace
maker implantation.