Mitral Stenosis

Report:

Sinus rhythm 99/min

Right axis deviation +125o

Late transition (clockwise rotation)

Left atrial abnormality

Small voltage in frontal leads

Comment:

The combination of LAA and presumptive RVH (from RAD and clockwise rotation) is suggestive of mitral stenosis. This patient had some mitral incompetence, but stenosis was the dominant lesion; hence the LV remained relatively small, allowing the RVH to be electrocardiographically manifest.

The LAA is, typically, quite marked, both as large PTF in V1 and classical, notched P mitrale (in L2 or V5).

As often happens, the postoperative (post-MVR, Fig 34a) trace was much less diagnostic; too many things happen at that time. The RAD went, but the R wave in V1 is now unequivocally dominant, with right precordial ST segment depression. Speaking of the RAD, the computer diagnosed it as LPHB in the original trace. This is a good example of why LPHB cannot be diagnosed on ECG grounds alone – it requires clinical exclusion of RVH.

Pericarditis

Report:

Sinus rhythm 85/min

ST segment elevation suggestive of acute pericarditis

LVH voltage

RL2 > 15 mm

Comment:

The typically concave-upward ST elevation is so widespread and marked that the only differential diagnosis, early repolarisation, is most unlikely. Further, the PR segment displacement is also present (albeit, as always, remaining just an exaggeration of the normal pattern); this would be unexpected in a 20 year old with normal heart. The computer went for early repolarisation, with the usual computer ‘explanation’: ST elevation, age 16-55!

Leads with deep S waves are often exempt from ST elevation in pericarditis, like aVL or V1 here.

Sarcoidosis

Report:

Sinus tachycardia 118/min

PR interval 0.20”

Right axis deviation

Alternating (2:1) right bundle branch block

Nonspecific ST/T changes

Possible lateral infarction ?age

Comment:

The tracing, of course, provides scant clues to its provenance. Clinically, the patient had congestive cardiomyopathy, with history of cerebral disease her neurologist, with unusual perspicacity or luck, thought might be sarcoid. This proved to be the case, on other grounds. She eventually had endomyocardial biopsy that proved cardiac involvement, said to be present in 20 –25% cases40.

AV and ventricular blocks are common, while pathological Q waves are not rare; looking at this trace one would be, perhaps, justified in thinking that there are not enough Q waves to produce an almost ‘trifascicular’ block, should the latter’s ætiology be ischæmic. Once sarcoidosis is confirmed elsewhere, this ECG becomes quite typical.

Below (Fig 36a) is a trace taken 2 days later, in RBBB throughout, and another, in 4:3 RBBB (Fig 36b).

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