Something wrong with this block

 A 65 yo with h/o HTN, CAD, S/P CABG c/o chest pain.

Figure 1 - ECG case

This is sinus bradycardia with right bundle branch block (RBBB) pattern in the precordial leads  (predominant R waves in V1). However, the T waves are upright in V2 and V3 and  not as inverted in V1. Typical RBBB pattern had T waves that are opposite in direction to the R waves.

Cardiac catheterization was done. It revealed a depressed LV systolic function (EF ~ 30%) with patent vein grafts to the right coronary artery and left anterior descending artery. Revascularization of the native AV groove circumflex artery with stent.

Figure 2 - post- cardiac catheterization ECG

The  ECG showed sinus rhythm with RBBB pattern but now the T waves are inverted in V1-V3.

So, this case is RBBB in the setting of a circumflex artery lesion.

Here is another article 

#634