HeartRhythm Case Reports

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HeartRhythm Case Reports

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HeartRhythm Case Reports Resolution of right bundle branch block after a premature ventricular beat: What is the mechanism? Jonathan Hillyard, DO, MS, Pranav Mankad, MD, Kenneth A. Ellenbogen, MD, FHRS, Santosh K. Padala, MD HeartRhythm Case Reports DOI: 10.1016/j.hrcr.2019.08.008 Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 1 Twelve-lead electrocardiogram showing a normal sinus rhythm with right bundle branch block at a rate of 60 beats per minute. Additionally, there are 2 ventricular premature contractions (VPC) that are followed by a post-VPC pause and subsequent narrow complex beat with complete resolution of the right bundle branch block. HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2019.08.008) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 2 Ladder diagram representing the underlying mechanism. A: Ventricular premature contraction (VPC) with left bundle morphology that penetrates the conduction system in a retrograde manner, as evidenced by retrograde P wave on surface electrocardiogram at the upslope of the T wave. B: Narrow complex beat with resolution of the right bundle branch block (RBBB) immediately following the VPC. C: Representation of Ashman phenomenon as the sinus impulse finds the right bundle refractory, resulting in RBBB aberrancy. D: Lastly, the RBBB is perpetuated in the subsequent beats by concealed retrograde penetration of impulses into the right bundle branch until a VPC ensues (A). A = Atria; AVN = atrioventricular node; BB = bundle branch; HIS = His bundle; LB = left bundle; RB = right bundle; VPC = ventricular premature contraction. HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2019.08.008) Copyright © 2019 Heart Rhythm Society Terms and Conditions