Report:

Sinus rhythm

Counterclockwise rotation (early transition)

Q waves in 2, 3, aVF, V2-6 noted

Minor T wave changes

Comment:

This is an example of a tracing impossible to interpret without the knowledge of its clinical context. The patient had congenital eventration of the left diaphragm, with marked cardiac displacement to the right. This is a postoperative ECG, taken in the hope of demonstrating a normalised trace. Disappointingly, the trace remained the same: a repeat CXR showed no change in cardiac position postoperatively. The heart had adhered to where it had been for 32 years209.

The ECG is characteristic of dextroposition: LV morphology (qR complexes) is recorded in right precordial leads, with diminishing voltages from V1 or V2 leftward. In the frontal plane, standard leads 1, 2 and 3 are orientated toward the left ventricle, as is aVF; lead aVR is typically an rS complex210.

There is a very similar example from Chou211, in a 40 year old woman with hypoplastic right lung.

Below (Fig 277a) is a look-alike – a 56 year old man who passed through our ICU with CABGs, whose heart was more rotated than displaced to the right. Fortunately for him, he never attracted the attention of a thoracic surgeon.

Pædiatric RVH

Report:

Sinus rhythm 175/min (upper limit for up to two years)

Right atrial abnormality, P congenitale type

Right axis deviation +170o

Right ventricular hypertrophy

RV1 > 5 mm

Comment:

The infant had a complex anatomy, not predictable per se on her ECG: common atrium, double-outlet RV, mitral atresia, hypoplastic LV, large VSD, partial anomalous venous drainage. Pulmonary artery was banded, palliatively.

Lead 2 is usually negative in pædiatric RAD as well as LAD; it’s 1 and aVF that distinguish them.