LVH: Left Ventricular Volume Overload

Report:

Atrial fibrillation with controlled response (56/min)

Left anterior hemiblock (frontal plane QRS axis -50o)

Poor R wave progression

Left ventricular hypertrophy (RV5 > 25 mm)

Prominent T waves consistent with LV volume overload

Comment:

The patient had dilated LV (6/3.8 cm) and LA (5.5 cm) with fractional shortening 77% and moderate-to-severe mitral incompetence. There was no echocardiographic evidence of old anterior infarction: the anteroseptal QS complexes were due to LVH ± lead positioning. Also, one would not expect large precordial voltages or “septal” q waves in V5-6 in the case of anteroseptal infarction.

Despite tall left precordial R waves, there are no ‘reciprocal’ deep S waves in V1-2: this is characteristic of mitral incompetence, reflecting anterior displacement of the QRS axis in the transverse (horizontal) plane202.

The "fine" atrial fibrillation, like the enlarged left atrium, imply long-standing and difficult to cardiovert AF. Even if sinus rhythm could be achieved, it would not be possible to maintain it.

Below (Fig 271a) is a trace taken more than a year later, showing another criterion of LVH (RV6 > RV5). Whether this is due to progression of LVH or different lead position remains unknown.