An Electrocardiographic Algorithm for Determining the Location of Pacemaker Electrode in Patients With Right Bundle Branch Block Configuration During Permanent Ventricular Pacing

Abstract

The expected morphology of right ventricular pacing is a left bundle branch block (LBBB) pattern. However, right bundle branch block (RBBB) can also be seen during permanent right ventricular pacing. The aim of this study was to develop an electrocardiographic algorithm to differentiate this benign condition from septal and free wall perforation with subsequent left ventricular pacing. Three hundred consecutive patients who had permanent ventricular or dual-chamber pacemaker implantation between 1999 and 2000 were screened and 25 patients (8.3%) who exhibited RBBB configuration were included in the study. Echocardiograms and chest radiographs were evaluated in order to identify the pacing lead location in this group. The authors formed a study group with their own 25 patients and 22 cases of RBBB with permanent pacemaker from previous publications (total 47 patients). Frontal axis, QRS morphology in lead V(1), and the precordial transition point, which is defined as the precordial lead where R wave amplitude is equal to S wave amplitude, were examined. Placement of precordial leads V(1) and V(2) 1 interspace lower than the standard location (Klein maneuver) eliminated the RBBB pattern in 12 patients. RBBB pattern with "true right ventricular pacing" was detected in 24 of the 25 patients, and in 11 of the 22 patients reported in the literature (total 35 patients). Right ventricular pacing was correctly identified in 34 of 35 patients with use of criteria including left superior axis deviation, RS or qR morphology in lead V(1), and precordial transition at lead V(3) with a high sensitivity and specificity. A simple surface electrocardiogram can accurately predict the lead location in patients having RBBB morphology with right ventricular pacing.

Renewed interest in the significance of the tall R wave in ECG lead V1 during right ventricular pacing

“…Okmen et al [7] (300 patients) and Coman and Trohman [8] (179 patient) also found an incidence of approximately 8%. The report of Klein et al [9] also indicated a relatively high incidence of 8 (16%) of 50 patients in a study where V1 lead was carefully checked for its correct position on the chest.…”

“…Almehairi et al [2] indicated that in 48 patients that an RV site is present with a transition ≤V3 yielding 96% sensitivity and 100% specificity. Okmen et al [7] had also evaluated precordial transition in 25 patients and found that a V3 transition resulted in a 97% sensitivity. Thus, precordial transition provides a high predictive value to rule out inadvertent LV pacing.…”

“…The ECG pattern with a truly posterior RV lead has not been systematically investigated as a potential cause of a tall R wave in V1 during RV pacing. The causes of a dominant paced R wave in lead V1 are well-known and include: Pacing in the myocardial relative refractory period, ventricular fusion, epicardial or endocardial left ventricular (LV) pacing, LV pacing from the coronary venous system, lead perforation of the RV with migration of the lead in the pericardial space towards the LV, and is noted in about 8-20% of cases of uncomplicated RV apical pacing [6][7][8][9][10][11][12][13][14]. It may also be due to placing lead V1 too high in the third or second intercostal space when a typical left bundle branch block pattern is recorded when the lead is appropriately in the 4 th intercostal space [3].…”

Przypadkowe umieszczenie elektrody stymulatora w lewej komorze serca u pacjenta z przetrwałym otworem owalnym – przypadek kliniczny

“…The shape of the QRS with morphology RBBB during right ventricular pacing can be distinguished from the shape of the QRS with morphology RBBB during left ventricular pacing according to the criteria described by Okmen et al: left axis deviation to the left in the frontal plane between -30 and -90 degrees, the transition zone in V3 lead (R-wave amplitude equal to the S-wave amplitude), the lack of S-wave in lead I and the sets of qR or RS in V1 lead. Nevertheless, each case of RBBB in ECG requires an accurate assessment of the electrode location [6].…”

Paradoxical Right Bundle Branch Block Morphology in Right Ventricular Apical Pacing- Is it Really Concerning?

“…Coman and Trohman [5] and Okmen et al [6] suggested an algorithm to separate RV and LV pacing morphology by using frontal axis and precordial transition point. After exclusion of pacing from proximal and mid septum, if there is a frontal axis of 0 to 90 degrees and precordial transition is by V3 then uncomplicated RV pacing can be distinguished from LV pacing with a sensitivity, specificity and positive predictive value of 86%,99% and 95% respectively.…”