Download ECG - De Gasperis

Roberto Pirola
Corso avanzato di
elettrocardiografia
ECG
28° CORSO PER INFERMIERI IN CARDIOLOGIA - DIPARTIMENTO CARDIOLOGICO «A. DE GASPERIS»
CORSO ECG AVANZATO
CORSO AVANZATO DI ELETTROCARDIOGRAFIA
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
CORSO AVANZATO DI ELETTROCARDIOGRAFIA
It is possible to distinguish lead reversal
and dextrocardia by watching the
precordial leads. Dextrocardia will not
show any R wave progression in leads V1V6, whereas lead reversal will.
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
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Dextrocardia and Dextroposition Definition
Dextrocardia: Electrical axis of the heart is directed inferiorly and to the right. There are several variants of dextrocardia:
1. Dextrocardia and situs inversus (mirror image dextrocardia): in addition to the heart, internal organs (of abdomen) are also positioned on the
opposite side.
2. Dextrocardia and situs solitus: Only heart is on the opposite side; internal organs are not affected.
Dextroposition: The anatomically corrected heart is displaced to the right hemithorax. Causes: deformities of chest wall, deformities of diaphragm,
postpneumonectomy, hypoplastic right lung, eventration of diaphragm, left hemidiaphragmatic paralysis, pneumomediastinum.
Mesocardia: The heart is placed in the midline of thorax. Apex of the heart is either in the midline or directed towards right.
Heterotaxy: (abnormal placement) Thoracic and abdominal organs are are placed abnormally. There is no right-left relationship between the organs:
neither situs solitus, nor situs inversus.
ECG criteria
In mirror-image dextrocardia, the axes of P wave, QRS complex and T wave are directed to the right and inferior.
This results in positive P waves in leads III and aVF and negative P waves in leads I and aVL. Not only the P wave, but QRS complex and T waves
are also negative in lead I.
In dextrocardia, normal progression of the R wave is not observed in chest leads.
Differential diagnosis
When arm leads are reversed the P wave becomes negative in lead I and positive in lead aVR. In addition to the P wave, QRS complex and T wave
are also negative in lead I.
However, reversal of arm leads does not affect R progression in chest leads resulting in an increase in R wave amplitude from lead C1 to C5:
normal R wave progression.
Clinical significance
In a patient with dextrocardia, it will be easier to comment on the ECG if the chest electrodes are symmetrically placed on right chest and the arm
leads are reversed
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
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Figure 1. Dextroposition, mirror-image dextrocardia and
congenitally corrected transposition of the great arteries.
The above figure is a modified version of a figure that originally
appeared in Military Medicine 2007;172:vii-ix (with permission).
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
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ECG 1a. The ECG above belongs to a 30
years-old woman. Precordial electrodes
are placed on left chest (standard
placement).
There is no R progression in chest leads.
Calibration is at 10 mm/mV
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
CORSO AVANZATO DI ELETTROCARDIOGRAFIA
ECG 1b. In order to see the P waves of
limb leads more clearly, the ECG was
recorded again at a calibration of
20mm/mV.
The chest electrodes are still on the left
side. The P wave is negative in leads I and
II, but positive in leads III and aVF.
No R wave progression is seen in the
anterior leads.
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
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ECG 1c. The above ECG belongs to the
same patient. This time, chest electrodes
are symmetrically placed on right chest
and
arm leads are reversed purposefully. Now,
R wave progression is seen in anterior
leads and the P wave is upright (positive)
in leads I and II. The ECG is calibrated at
10 mm/mV
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
CORSO AVANZATO DI ELETTROCARDIOGRAFIA
ECG 1d. The electrodes are placed same
as in ECG 1c; only the calibration is 20
mm/mV
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
CORSO AVANZATO DI ELETTROCARDIOGRAFIA
ECG 2a. This ECG belongs to a 52 years old man who
had undergone stenting of the right coronary artery for
the treatment of
acute inferior wall myocardial infarction 1 year ago. The
ECG above was recorded during a routine control and
the patient
was asymptomatic. There are Q waves and negative T
waves in the inferior leads. Lacking ST elevation and
typical chest pain,
these ECG findings suggest OLD inferior wall
myocardial infarction. The patient also has
dextrocardia. Because of
dextrocardia, QRS complex and T wave are upright in
lead aVR while they are negative in lead I . This finding
is not due to
arm lead reversal since there is no expected R wave
progression in the chest leads. Contrarily, the amplitude
of the R wave
decreases from C1 to C6.
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
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ECG 2b. The above ECG belongs to the
same patient but was recorded after the
electrodes were symmetrically placed on
the
right chest. The ECG now shows proper R
wave progression . Old inferior myocardial
infarction and abnormal appearance in
lead aVR persists
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
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ECG 3a. The ECG tracing above belongs
to an 11 years-old girl and shows leads I, II
and III. She has right lung agenesis
(complete absence of right lung) and
dextrocardia.
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012
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ECG 3b. Leads aVR, aVL and aVF of her
ECG.
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
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ECG 3c. Leads V1, V2 and V3 of her ECG
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RP 5/2012
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ECG 3d. Leads V4, V5 and V6 of her ECG
Gruppo di miglioramento – Ospedale Niguarda Ca’ Granda, Milano – Maggio 2012
RP 5/2012