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An Atypical Pattern of Right Ventricular Hypertrophy
ELECTROCARDIOGRAM OF THE MOI\:TH
An Atypical Pattern of Right Ventricular Hypertrophy* ERNESTO
P.
A. ARCILLA, M.D . M . GASUL, M.D ., F .C.C.P.** Chicago, Illinois
NAMlN, M .D., RENE
AND BENJAMIN
A TYPICAL PATTERNS OF RIGHT VENTRIC-
r1... ular hypertrophy often
escape the eye of the unwary observer and may be misinterpreted as indicative of left ventricular hypertrophy. The vectorcardiogram and electrocardiogram presented here belong to a colored female baby who was born cyanotic with a birth weight of four pounds. On the second day of life, dyspnea appeared and since then, until her demise at age 11 months, she had persistent congestive heart failure and cyanosis. At necropsy, the mutual relationships between the cardiac chambers and great vessels were normal. The right atrium was hypertrophied and dilated while the left atrium was minute and thin-walled and received the pulmonary veins in a normal manner. The right atrioventricular opening led into both ventricular chambers and was guarded by a valve which was anchored, as in a common atrioventricular canal, to papillary muscles in both ventricles. There was no left atrioventricular orifice. The only opening leading from the left atrium was patent foramen ovale that measured 4 mm . in its greatest dimension. The right ventricle was hypertrophied; the left ventricle was normal-sized. Between these chambers was a ventricular septal defect measuring 1.5 em. in diameter. The aortic orifice had a circumference of 2.7 em. An accurate measurement of the true size of the pulmonary orifice was not possible because of a previous surgical pr()-From the Department of Pediatric Cardiophysiology, Cook COUDty Children's Hospital and Hektoen Institute for Medical Research, and the Department of Pediatrics , University of Illinois College of Medicine.
cedure involving banding of the pulmonary artery. The QRS sE loop of the vectorcardiogram taken with the cube electrode placement is oriented posteriorly, superiorly, and to the right. The initial forces are directed anteriorly, inferiorly, and to the left. The frontal loop is inscribed in a counterclockwise direction and has a mean axis directed superiorly and to the right-a pattern seen commonly in endocardial cushion defects. The horizontal QRS sE loop is initially counterclockwise , rotates in the opposite direction towards its distal extremity, and describes a figure-of-eight pattern. The mean horizontal axis is directed posteriorly and to the right. This is in contrast to the usual pattern of right ventricular hypertrophy in which the horizontal QRS sE loop is oriented mainly anteriorly and to the right and rotates in a dominantly clockwise direction. The first electrocardiogram shows primarily negative deflections in the right precordium and low voltage positive deflections in V 3' V 6' and V 7' The electrocardiogram at five and one-half months retains essentially the same pattern as the first. The deeper S waves in the left precordial leads denote a farther rightward shift of the QRS forces. The deep S waves in the right precordial leads are again in contrast to the typical pattern of right ventricular hypertrophy which shows a dominant R. To summarize, this ll-month-old baby showed at necropsy dilated and hypertrophied right atrium, mitral atresia, hypertrophied right ventricle, ventricular septal
--Deceased .
207
208
Diseases of the Chest
NAMIN, ARCILLA AND GASUL
defect of the common A-V canal type, patent foramen ovale and normal sized left
ventricle. The graphic data are atypical examples of proved right ventricular hypertrophy. II
III
aV R
aVL
Readers are invited to submit articles for the Electrocardiogram of the Month. Please submit materlal to Stephen R. Elek, M.D.. 6423 W11ah1re Boulevard. Los Angeles.
An Atypical Pattern of Right Ventricular Hypertrophy* ERNESTO
P.
A. ARCILLA, M.D . M . GASUL, M.D ., F .C.C.P.** Chicago, Illinois
NAMlN, M .D., RENE
AND BENJAMIN
A TYPICAL PATTERNS OF RIGHT VENTRIC-
r1... ular hypertrophy often
escape the eye of the unwary observer and may be misinterpreted as indicative of left ventricular hypertrophy. The vectorcardiogram and electrocardiogram presented here belong to a colored female baby who was born cyanotic with a birth weight of four pounds. On the second day of life, dyspnea appeared and since then, until her demise at age 11 months, she had persistent congestive heart failure and cyanosis. At necropsy, the mutual relationships between the cardiac chambers and great vessels were normal. The right atrium was hypertrophied and dilated while the left atrium was minute and thin-walled and received the pulmonary veins in a normal manner. The right atrioventricular opening led into both ventricular chambers and was guarded by a valve which was anchored, as in a common atrioventricular canal, to papillary muscles in both ventricles. There was no left atrioventricular orifice. The only opening leading from the left atrium was patent foramen ovale that measured 4 mm . in its greatest dimension. The right ventricle was hypertrophied; the left ventricle was normal-sized. Between these chambers was a ventricular septal defect measuring 1.5 em. in diameter. The aortic orifice had a circumference of 2.7 em. An accurate measurement of the true size of the pulmonary orifice was not possible because of a previous surgical pr()-From the Department of Pediatric Cardiophysiology, Cook COUDty Children's Hospital and Hektoen Institute for Medical Research, and the Department of Pediatrics , University of Illinois College of Medicine.
cedure involving banding of the pulmonary artery. The QRS sE loop of the vectorcardiogram taken with the cube electrode placement is oriented posteriorly, superiorly, and to the right. The initial forces are directed anteriorly, inferiorly, and to the left. The frontal loop is inscribed in a counterclockwise direction and has a mean axis directed superiorly and to the right-a pattern seen commonly in endocardial cushion defects. The horizontal QRS sE loop is initially counterclockwise , rotates in the opposite direction towards its distal extremity, and describes a figure-of-eight pattern. The mean horizontal axis is directed posteriorly and to the right. This is in contrast to the usual pattern of right ventricular hypertrophy in which the horizontal QRS sE loop is oriented mainly anteriorly and to the right and rotates in a dominantly clockwise direction. The first electrocardiogram shows primarily negative deflections in the right precordium and low voltage positive deflections in V 3' V 6' and V 7' The electrocardiogram at five and one-half months retains essentially the same pattern as the first. The deeper S waves in the left precordial leads denote a farther rightward shift of the QRS forces. The deep S waves in the right precordial leads are again in contrast to the typical pattern of right ventricular hypertrophy which shows a dominant R. To summarize, this ll-month-old baby showed at necropsy dilated and hypertrophied right atrium, mitral atresia, hypertrophied right ventricle, ventricular septal
--Deceased .
207
208
Diseases of the Chest
NAMIN, ARCILLA AND GASUL
defect of the common A-V canal type, patent foramen ovale and normal sized left
ventricle. The graphic data are atypical examples of proved right ventricular hypertrophy. II
III
aV R
aVL
Readers are invited to submit articles for the Electrocardiogram of the Month. Please submit materlal to Stephen R. Elek, M.D.. 6423 W11ah1re Boulevard. Los Angeles.