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Bundeltackblok

BUNDELTAKBLOK

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1. Oorzaken

mechanismen:
- blokkade thv de intraventriculaire bundels
     - links: LBBB: vetraagde depolarisatie linker ventrikel.  Linker bundeltak
          splitst in 2 fascikels.  Anterieur: LAF (linker anterieure fascikel) en
          posterieur: LPF (linker posterieure fascikel)
     - rechts: RBBB: vetraagde repolarisatie rechter ventrikel
     - Bifasciculair blok: RBBB + LAF of LPF
- onvolledig of volledig?
     - onvolledig: vertraagde depolarisatie.  QRS complex >/= 100ms (2,5 vakjes)
          maar minder dan 120 ms (< 3 kleine vakjes)
     - volledig: 1 bundel is volledig disfunctioneel.  Er is een tragere conductie via de
          spieren zelf.  QRS > 120 ms (> 3 kleine vlakjes)
oorzakelijke aandoeningen:
- cardiaal:
- AMI
- cardiomyopathie
- ouderdomsfibrose van de Purkinjevezels
- kleplijden
- atrium-septumdefect
- na hartchirurgie
- Brugada Syndroom (RBBB als oorzaak van plotse dood bij gezonde patn)
- medicatie
- Betablokkers
- calciumantagonisten
- TCA's
- anti arrhytmica (type 1a en 1c)
- Digitalis
- Hypertensie
- soms oefedning-geinduceerd
- Ziekte van Chaga (vooral Centraal Amerika en Zuid Amerika)

 

2. Kliniek

Dit varieert van asymptomatisch tot syncopaal (op ventrikeltachycardie) en thoracale pijn.

 

3. Diagnostiek

- lichamelijk onderzoek
- RBBB: S2 splitsing, ook tijdens expiratie
- LBBB: paradoxale S2 splitsing
- EKG
- volledig bundeltakblok (QRS > 120 ms = 3 vakjes)
- RBBB: QRS-complex in rechter afleidingen (V1 of V2) heeft 90% een M-vorm (rsR', rsr', rSR') en 10% een notched R.  In de linkerafleidingen (V5 en V6) is de S-golf breed en diep.  Bij het Brugada-syndroom zie je een combinatie van RBBB en ST- elevatie in V1, V2 en V3
- LBBB: QRS complex in de rechter afleidingen (V1-V2) is de q klein of afwezig en de R=klein.  De S domineert het complex (is diep, breed, scherp en heeft geen notch)  In de linkerafleidingen (V5, V6, aVL en I) is het complex monofasisch, dwz geen q of s, alleen R als brede onregelmatige R-golf en meestal notched.
- OPGELET!: zodra LBBB kan je niets meer zeggen over ischaemie op ECG
- onvolledige bundeltakblok (QRS >/= 100ms maar < 120 ms)
-RBBB en LBBB hebben zelfde vormen QRS als bij volledig blok.
- fasciculair blok
- LAF blok: QRS is wel verlengd maar < 120 ms (< 3 kleine vakjes).  Er is een asdeviatie tussen -45° en -90°.  De S is diep in II, III en aVF.  Er is een qR in I en aVL
- LPF blok: QRS isd wel verlengd maar < 120 ms (< 3 kleine vakjes)  Er is een asdeviatie van >/= 120°.  Er is een RS in I en aVL en een qR in II, III en aVF
- LABO: electrolieten (K+) en hartenzymen (ischaemie)
- RX-thorax

- electrofysiologisch onderzoek bij onverklaarde syncope

 

 

Eerste opvang

- standaard opvang
- ischaemie
- syncope
- dyspnee
- transcutane pacing

- indien bifasciculair blok of symptomatische 2e en 3e graads blok

 

Spoeddienst

- indien asymptomatisch: geen behandeling
- bij nieuwe LBTB: dit is steeds suggestief voor AMI.  Overweeg thrombolyse
- transveneuze pacemaker zo nodig
 
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