Left Posterior Fascicular Block (LPFB)
In left posterior fascicular block (previously left posterior hemiblock), impulses are conducted to the left ventricle via the left anterior fascicle, which inserts into the upper, lateral wall of the left ventricle along its endocardial surface.
- On reaching the ventricle, the initial electrical vector is therefore directed upwards and leftwards (as excitation spreads outwards from endocardium to epicardium), causing small R waves in the lateral leads (I and aVL) and small Q waves in the inferior leads (II, III and aVF).
- The major wave of depolarisation then spreads along the free LV wall in a downward and rightward direction, producing large positive voltages (tall R waves) in the inferior leads and large negative voltages (deep S waves) in the lateral leads.
- This process takes up to 20 milliseconds longer than simultaneous conduction via both fascicles, resulting in a slight widening of the QRS.
- The impulse reaches the inferior leads later than normal, resulting in a increased R wave peak time (= the time from onset of the QRS to the peak of the R wave) in aVF.
ECG Criteria for Left Posterior Fascicular Block (LPFB)
- Right axis deviation (RAD) (> +90 degrees)
- Small R waves with deep S waves (= ‘rS complexes‘) in leads I and aVL
- Small Q waves with tall R waves (= ‘qR complexes‘) in leads II, III and aVF
- QRS duration normal or slightly prolonged (80-110ms)
- Prolonged R wave peak time in aVF
- Increased QRS voltage in the limb leads
- No evidence of right ventricular hypertrophy
- No evidence of any other cause for right axis deviation
- rS complexes in leads I and aVL
- qR complexes in II, III and aVF
Right Axis Deviation (RAD)
- Leads II, III and aVF are POSITIVE;
- Leads I and aVL are NEGATIVE
Prolonged R-wave peak time
- R-wave peak time: Time from onset of the QRS to the peak of the R wave in aVF > 45 ms
- LPFB is much less common than LAFB, as the broad bundle of fibres that comprise the left posterior fascicle are relatively resistant to damage when compared with the slim single tract that makes up the left anterior fascicle.
- It is extremely rare to see LPFB in isolation. It usually occurs along with RBBB in the context of a bifascicular block.
- Do not be tempted to diagnose LPFB until you have ruled out more significant causes of right axis deviation: Example: acute pulmonary embolus; tricyclic overdose; lateral STEMI; and right ventricular hypertrophy.
ECG Examples of LPFB
- Left bundle branch block LBBB
- Right Bundle Branch Block RBBB
- Left anterior fascicular block LAFB
- Left posterior fascicular block LPFB
- Interventricular Conduction Delay IVCD
- Bifascicular block
- Trifascicular block
- Complete Heart block CHB
LITFL Further Reading
- ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis – ECG interpretation in clinical context
- ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
- 100 ECG Quiz – Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS – the best of the rest
- Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric
- Wagner GS. Marriott’s Practical Electrocardiography 12e
- Chan TC. ECG in Emergency Medicine and Acute Care
- Rawshani A. Clinical ECG Interpretation
- Mattu A. ECG’s for the Emergency Physician
- Hampton JR. The ECG In Practice, 6e