Combination of dextrocardia, bundle branch block, and myocardial infarction

Diagnostic

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Corn bination of Dextrocardia, Bundle Branch Block, and Myocardial Infarction Case Report with Vector Analysis of Electrocardiogram DONALD C. FISCHER, Cincinnati,

T

HIS

case is reported

to emphasize

bundle

combining branch

recorded

Its usefulness is exemplified

here in the interpretation tracing,

of a complex

the patterns

abnormal

of dextrocardia,

block, and acute myocardial

in-

farction in a single cardiogram. CASE HISTORY The

patient,

an 89-year-old

white female,

Ohio

moderately distended and the liver questionably palpable one finger’s breadth below the left costal margin and nontender. Pulses were palpable throughout and no peripheral edema was present. Laboratory jindings of significance included : PCV 38, hemoglobin 12.0 gm, WBC 7,750 with a normal differential, sedimentation rate 25 mm/hr, prothrombin time 75 per cent of normal. The urinalysis was normal, BUN Serology was negative. A chest 14.0, blood sugar 122. x-ray showed dextrocardia with cardiac enlargement, in-

the value

of vector analysis of the routinely

electrocardiogram.

M.D.

was ad-

mitted to Good Samaritan Hospital on March 31, 1957 complaining of right upper abdominal pain of several During the week prior to admission she hours’ duration. had experienced three episodes of similar pain, each lastIn the interim periods she was ing less than one hour. apparently without symptoms. The pain was like a and no associated sweating or dyspnea “gas-pressure,” The pain was not referred. was noted. Her significant past history included the knowledge She had a nonthat her heart was “in the right chest.” functioning gall bladder and nonfunctioning left kidney No definitive revealed by x-ray examinations in 1953. therapy for these conditions had been performed. Some five years prior to her present admission she had undergone surgery for a small bowel obstruction caused by adhesions about a ruptured ovarian cyst. Physical examination at the time of admission revealed: Temperature 98, pulse 90, respirations 26, blood pressure Exam138/80. The patient was not in acute distress. ination of the lungs revealed scattered basilar rales and The some diminution of breath sounds in both bases. PM1 was in the 6th intercostal space at the right midclavicular line. Heart rate was 90/min and regular; a basilar, grade 3 systolic murmur was heard, loudest in The abdomen was the aortic region; no thrill was felt.

“i

770

“6

“5

Fig. 1. Electrocardiogram sion to hospital. THE

AMERICAN

recorded

JOURNAL

at time of admis-

OF

CARDIOLOGY

Fischer

\

I I

\

YEAN \

QRS

\ ‘1 \ \ ‘\

TBlY*NAl.

\

.01

\

----

Tf++ / /

5

I

I /

’

.a

I

SEC.

QRS.

ST.,: __----

_ - - - - _ ----

\ \

‘, \

‘\

\

SPC.

QRS.

I

\

,’

(A) Fig. 2. (A) Frontal plane view of vectors involved in the writing of the electrocardiogram vectors, as viewed in the anterior-posterior plane of the chest.

creased perivascular pleural effusion.

markings,

and minimal

bilateral

The electrocardi’ogram

is shown in Figure

1.

The analysis of this -tracing by plotting of the vecforces involved is represented in Figures 2A and B. The following points are of particular in the figures, according

lined by Grant and Estes.’ (1) The vector representing same general

complex

direction

2B)

the

first

0.04

does not point in the QRS vecIt is rotracing.

180” in space from the mean

and points

out-

as the mean

tor, as one sees in a normal tated almost

to criteria

inferiorly

and posteriorly

(Fig. from

the sternum. (2) The T wave vector also points almost directly

posteriorly

from

the sternum

(Fig.

superiorly,

establishing

the ventricles

torial

set of the QRS

somewhat

(Fig. 2A),

ANALYSIS OF ELECTROCARDIOGRAMS

interest

teriorly,

and

(blocked)

of

and, therefore,

the electrical

impulse

lies in this area

from an electrical

to the left

that the last portion

to be depolarized,

the area to which layed

(B) Same

in Figure 1.

is de-

of the chest,

viewpoint. COMMENT

The only cardiac account would

abnormalities

for this combination be dextrocardia,

right

block, and acute myocardial area of anteroseptal the

QRS

terminal

point

infarction

myocardial

and the vector QRS

events

bundle

branch simulta-

The ST vector points to the

neously recorded. T vector

which would

of electrical

directly vector

infarction,

the

of the first 0.04 set of away

from

it.

The

points to the part of the

2B),

forming a large angle with the mean QRS vecThis angle would normally be 60” or less. tor. (3)

The vector of the ST segment is directed

distinctly sternum plane.

anteriorly

(Fig.

2B),

pointing

at the

and nearly perpendicular to the frontal In the normal ECG, and even with dex-

trocardia and bundle branch block combined, this vector should assume the same general pathway as the T vector. (4) The vector of the final 0.08 set of the QRS,

as well as the mean QRS

DECEMBER,

1958

vector, point an-

“4 v2 b3 Fig. 3. Supplemental chest leads recorded 12 hours after admission to hospital.

772

Dextrocardia,

right ventricle tricular The

farthest

depolarization possibility

that

from the source of ven:

an ECG representing cardiac

this pattern

block could

actually

farction

block was considered,

of bundle

represent

peri-in-

of the terminal

tor toward

ventricle

QRS

rather

in peri-infarction

branch

myocardial

block,

the terminal

vector

block simulating

at a later date to substantiate

the

RBBB

pointed

to emphasize proach

acute

of

right

anteroseptal

the value

of this method

in the interpretation

is shown of ap-

of the routinely

re-

corded electrocardiogram.

in the

ECG leads taken

REFERENCES 1.

the exact area of

infarction.

R. P. and ESTESE. H. : Spatial Vector Electrocardmgraphy. Blakiston, New York, 1952, pp. 68,

GRANT,

98-100. SUMMARY

(1)

and

dextrocardia,

infarction.

series reported by Dodge and Grant.* Figure 3 shows supplemental

of

(2) The vector analysis of the ECG

vec-

than

This vector also points well outside of

the area to which

bundle

an unusual combination

abnormalities

but seems elimi-

nated by the direction infarct.

Infarction

(Fig. 2B).

branch

the right

BBB, and Myocardial

A case report is presented which revealed

2.

R. P. and DODGE, H. T.: Mechanisms of QRS complex prolongation in man: right ventricular conduction defects. Am. J. Med. 21: 534,1956.

GRANT,

THE

AMERICAN

JOURNAL

OF CARDIOLOGY