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RV pacing dyssynchrony on echocardiography

Similar to LBBB: abnormal activation from the RV apex, with a pacing spike before a broad QRS on the ECG. Thickening is preserved.

Watch it in the simulator →Practise random cases

Where to look

Apical 4-chamber and PSAX; the ECG strip shows a pacing spike before a broad QRS.

Typical wall-motion pattern

Right ventricleRV1. Basal anterior — Normal12. Basal anteroseptal — Normal23. Basal inferoseptal — Normal34. Basal inferior — Normal45. Basal inferolateral — Normal56. Basal anterolateral — Normal67. Mid anterior — Normal78. Mid anteroseptal — Normal89. Mid inferoseptal — Normal910. Mid inferior — Normal1011. Mid inferolateral — Normal1112. Mid anterolateral — Normal1213. Apical anterior — Normal1314. Apical septal — Normal1415. Apical inferior — Normal1516. Apical lateral — Normal1617. Apex (apical cap) — Normal17ANTINFSEPLAT
4C3. Basal inferoseptal — Normal39. Mid inferoseptal — Normal914. Apical septal — Normal1417. Apex (apical cap) — Normal1716. Apical lateral — Normal1612. Mid anterolateral — Normal126. Basal anterolateral — Normal6Right ventricleRVSEPLAT2C4. Basal inferior — Normal410. Mid inferior — Normal1015. Apical inferior — Normal1517. Apex (apical cap) — Normal1713. Apical anterior — Normal137. Mid anterior — Normal71. Basal anterior — Normal1INFANT3C5. Basal inferolateral — Normal511. Mid inferolateral — Normal1116. Apical lateral — Normal1617. Apex (apical cap) — Normal1713. Apical anterior — Normal138. Mid anteroseptal — Normal82. Basal anteroseptal — Normal2Right ventricleRVINF-LATANT-SEPSAX baseRight ventricleRV1. Basal anterior — Normal12. Basal anteroseptal — Normal23. Basal inferoseptal — Normal34. Basal inferior — Normal45. Basal inferolateral — Normal56. Basal anterolateral — Normal6SAX midRight ventricleRV7. Mid anterior — Normal78. Mid anteroseptal — Normal89. Mid inferoseptal — Normal910. Mid inferior — Normal1011. Mid inferolateral — Normal1112. Mid anterolateral — Normal12

Example: RV apical pacing

All 17 segments thicken normally.

EF in this example: 42% (Impaired (36–49%)).

1 Normal2 Hypokinetic3 Akinetic4 Dyskinetic5 Aneurysmal

Ejection fraction

Across 24 simulated cases of this pattern the true EF ranged from 39% to 46% (median 41%, Impaired (36–49%)). Every case in the simulator is different, so practise until your visual estimate lands in the right 5% range.

Teaching points

Common pitfalls

As with LBBB, abnormal motion with preserved thickening is not an RWMA.

Try it now: open the RV pacing dyssynchrony example with the segment overlay, then test yourself in Practice where cases are random and graded against the exact answer.

Other patterns