[PDF] ELECTROCARDIOGRAM IN THE TETRALOGY OF FALLOT - Heart



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ELECTROCARDIOGRAM IN THE TETRALOGY OF FALLOT - Heart BY

ARNOLDWOODS

ReceivedJuly21,1951

ThefeaturesofthestandardlimbleadelectrocardiograminthetetralogyofFallotweredescribedbyBakeretal.(1949).InallexcepttheearliercasesatGuy'sHospitalunipolarlimbandchestleadshavealsobeenrecorded.Thepurposeofthispaperistopresenttheircharacteristicsin52casesinwhichthediagnosiswaswellestablished.In15casesthediagnosishasbeenconfirmedbypost-mortemexamination:someoftheseandalltheotherswereoperatedonbyMr.R.C.Brockwitheitherasystemic-pulmonaryanastomosis,apulmonaryvalvulotomy,oraninfundibularresection,andmostwereinvestigatedbycardiaccatheterizationorangiocardiographybeforeoperation.Theagesofthepatientswere3-10yearsin32,11-20yearsin18,24yearsin1,and34yearsinthelast.AlltherecordsweretakenwiththeSanbornvisocardiettedirect-writingelectrocardiograph.In38casestheunipolarleadscomprisedaVR,aVL,aVF,andVItoV6,whileintheremaining14aVL,aVF,VI,Y3andV5wererecorded.In7casesleadswerealsotakentotherightofVI.PWave.AshasalreadybeennotedbyBakeretal.(1949),tallpointedPwavesareastrikingfeatureinthestandardleads,especiallyinleadII(Fig.1).Inthese52casesPllvariedfrom1mm.to5mm.inheight,withaninversionof 2mm.inonecase.In35percenttheheightwasof2-5mm.ormore(TableI).

TABLEI

Height(inmnm.)

051_115225345

NumberII161116 7740ofcasesV1-V345131251111

ThePwaveswerealsomoreprominentthannormalintheunipolarleads,especiallyfromtherightsideofthechest.InVitoV3,withthetallestPgenerallyinV1,theheightrangedfrom05to5mm.In35percenttheheightwasof25mm.ormore(TableI).Inonly25percentwasPmostprominentinVItoV3,andinafurther25percenttheheightinVItoV3,wasequaltothatinII,whilstPlIwasmostprominentin42percent.In8percentPinleadIoraVLwastallerthanintheotherleads.P-RInterval.InnocasewastheP-Rintervalprolongedbeyondnormallimits.Therangewasfrom0-12to0-18sec.,withanaverageof0-15sec.QRSComplex.ThedurationoftheQRScomplexwaswithinnormallimits,005-008sec.,inallleadsin50cases(96%).Intheremaining2casesthedurationinViandoneormoreother193 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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ARNOLDWOODS

leadswas0I10sec.or0-11sec.,suggestingincompletebundlebranchblock,althoughinneitherofthesewasanrsR'patternpresent(Fig.2).Therewasnoexampleofcompleterightbundlebranchblock.InonecasetherewasanrsR'S'complexinVI,butthedurationwasonly007sec.VIshowedaslurredRoranrRcomplex(Fig.3)in23cases(44%),andaqRin8(15%).Ofthe23caseswithaslurredRoranrRcomplex,only3wereamongstthe15deathsintheseries,whileallthe8caseswithaqRcomplexwereamongstthedeaths.InV6aqRoccurredin20cases(39%);in2aqRwaspresentinallthechestleadsfromVItoV6.IntrinsicDeflection.Theintrinsicdeflectionwasmeasuredin50cases.InVItherangeofthetimesoftheintrinsicdeflectionwasbetween0-01and0'07sec.,withthemajority(68%)004-005(TableII);94percentweredelayedto003sec.ormore.Therewerenocasessuggestingcompleterightbundlebranchblock,thedelayneverbeinggreaterthan0-07,butin20(40%)itwasbetween005and007sec.InV6therangewasfrom0-01to0-04,with74percentlessthan003(TableII).AfurtherindicationofthedegreeofrightventricularhypertrophyisgivenbythedifferencebetweentheintrinsicdeflectionsofVIandV6;inV6, 96percentwereeitherlessthan(94%o)or equalto(2%)thoseinVI(TableIII).OneofthetwoexceptionsisshowninFig.4.RandSWaves.Inthestandardleadsrightaxisdeviationwaspresentinallbutonecase(98%).AsnotedbyBakeretal.(1949),itwasofsuchadegreethatrightventricularpreponderancewassug-194 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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TABLEII

Intrinsicdeflection(insec.)

001002003004005006007

NumberVI126211352ofcasesV61324103---195 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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ARNOLDWOODS

TABLEIII

I.D.inV6-I.D.inVI(insec.)

-005-0104-003-0102-0010+0101+0-02+003

Numberofcases281116 101011

gestedbythestandardleadsalone.RwassmallandSdeepinI,whileinIII,RwasprominentandSabsentinthemajority(88%)andsmallintherest.Intheremainingcasethemaindeflectionswereallnegative,producingtheSSSpatternattributedbyGoldbergerandSchwartz(1945)tobackwarddisplacementoftheapexinaverticalheart.Intheunipolarlimbleads,accordingtothecriteriaofGoldberger(1949),findingscharacteristicofaverticalheartwerepresentin49cases(94%);inonethepositionwashorizontalandintwointer-mediate.However,accordingtoWilsonetal.(1944),theelectricalpositionoftheheartwouldhavetoberegardedashorizontalin38cases(73%),verticalin7(13%),andintermediatein7(13%)andthisismoreinaccordwiththeanatomicalpositionsasassessedradiologicallybyscreening.InaVL,rScomplexeswerepresentin30cases,QSin13,andqrSin7,withanRinoneandRsinone;thusthedominantdeflectionwasanSwavein50cases(96%).InaVF,qRcomplexeswerefoundin21cases,Ralonein12,Rsin9,qRsin6,RSin2andQSandrSinonecaseeach;thusadominantRwaspresentin48cases(92%).InaVR,whichwasrecordedin40cases,theQwavewaslessthan25percentoftheRwave196 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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TABLEIV

THESIZEOFRANDSINVIANDV6IN52CASES

Sizeinmm.

2010-205-905-40

RV1221974SVI1361527RV60817270SV611112235

TABLEV

(aVRWASRECORDEDINONLY39CASES)

PositiveNegativeDiphasicIsoelectric

in21,whilein6furthercasesitwas25-50percentoftheRwave;thusin68percenttherewasaqRpatterntypicalorsuggestiveofrightventricularhypertrophy.Intherestnormalpatternswerefound,eitherQr(15%),QRwhereQwas50-100percentoftheRwave(15%)orQS(2%).InVI,RwasgenerallytallandSabsentorsmall.In41cases(78%)Rwas10mm.ormore,whileSwaslessthan5mm.in42(81%)andabsentin27(52%)(TableIV).In48cases(92%)RwaslargerthanSinVIintheinitialelectrocardiogram(Fig.1).IntheotherfourcasesfurtherleadsweretakentotherightofVIandinthreeRwasgreaterthanSinV3R;inasubsequentelectrocardiogramofoneofthesecasesthetruerightventricularhypertrophypicturewithRdomi-nancewasfoundonlyinV4R.Thus,altogether51cases(98%)showedadominanceofRoverS,i.e.areversalofthenormalR/Sratio,intherightpectorallead;theremainingcase(Fig.4)willbediscussedlater.InV6therewasrelativeprominenceofS,whichwas5mm.ormorein24cases(46%),whileRwaslessthan10mm.in45(86%).SwasgreaterthanRin46percent,equaltoRin12percent,andsmallerin42percent.R-STSegment.In18cases(35%)therewasR-STdisplacement,butusuallyonlyof05mm.inthestandardleadsand1mm.orlessintheprecordialleads,andnevermorethan2mm.ineither.TWave.InthestandardleadsTwasfrequentlyinvertedinleadIII,butwasnormallyuprightinleadsIandII.IntheunipolarlimbleadsTwasinvertedinallbut2ofthe40casesinwhichaVRwasrecorded.InaVLanuprightTwasmorethan3timesascommonasaninvertedT,whileinaVFTwasuprightin47cases(90%)(TableV).IntheprecordialleadsTwaveinversionwasusuallypresentinonlyVIornotatall,butin5casesitextendedtoV2orV3,in2casestoV4(Fig.4),andinonecase(Fig.5)acrossthewholechesttoV6(TableVI).UWave.Uwaveswerefoundinoneormorestandardorunipolarleadsin18cases(35%),197 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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ARNOLDWOODS

TABLEVI

NilVIToToTOToTO

V2V3V4V5V6

Numberofcases143023201

TABLEVII

THESITEOFTHETRANSMIONZONEIN52CASES

FIG.5.-TwaveinversionispresentinallprncordialleadsfromVltoV6.Recordtakenbeforeoperation(Case0203).198 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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TABLEVIII

0047..1208434/6P048..907517/10246..15122/20224..270121010/0P023..1008734/0D.C..-9819/100187..22091016/0199 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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DISCUSSION

ThecriteriaforanelectrocardiographicdiagnosisofrightventricularhypertrophyweredescribedbyMyersetal.(1948),andthesewillbeusedprimarilyasabasisfordiscussion.InthisseriestheelectrocardiogramofFallot'stetralogyfulfilledthemajorityofthesecriteriainmostcases.ThereversalintheratiooftheamplitudesofRandSinthechestleadswasapredominantfeature,thechangesoccurringmostfrequentlyinVIwhereRwasgreaterthanSin98percent.Intheremainingcase(Fig.4)anunusualdegreeofrotationandbackwardtiltingoftheapexhasresultedinanrScomplexinVI.InV6,Swaspresentin90percent,butinonly46percentwasitlargerthanR;insomecasestherelativelytallRwasthoughttobeduetothemarkeddegreeofclockwiserotationfoundinmanycasesofFallot'stetralogy,thedominantRusuallypresentinVIsometimesextendingasfarovertotheleftsideasV6orV7.Delayintheonsetoftheintrinsicdeflectionto0O03sec.ormorewasfoundin94percentofcases.SokolowandLyon(1949),in60casesofrightventricularhypertrophy,foundadelayto0-04sec.ormorein70percent.Donzelotetal.(1951)foundadelayto003sec.ormorein84percentinFallot'stetralogy,andconsideredthedifferentialindexbetweentheintrinsicdeflectionsinV6andVItobethemostconsistentevidenceofrightventricularhypertrophy,forinall100casesintheirseriesthisfigurewasnegative(98%)orzero(2%),andthisneveroccurredinnormalsorcasesofleftventricularhypertrophy.Thecomparablefiguresinthisserieswere94percent(nega-tive)and2percent(zero).InonecaseR/SinVIwas1/19butthedelayintheintrinsicdeflectioninVlwas004andthedifferentialindexwasnegative(-003),thusaffordingevidenceofrightventricularhypertrophy.QinV1wasthoughtbyMyersetal.(1948)tobecommonlypresentinrightventricularhyper-trophy,butonlyasmallproportionoftheirserieswerecasesofFallot'stetralogy.Donzelotetal.(1951)founditinonly7percentinFallot'stetralogy,andSodi-Pallares(1950)consideredthattheqRpatterninVIisconfinedalmostentirelytotherightventricularhypertrophyduetorheumaticheartdiseaseandtochroniccorpulmonale.InthisseriesaqRcomplexwaspresentin8cases(15%)andall8wereamongthe17deaths(i.e.47%ofthedeaths).ThissuggeststhatQappearsinViincaseswithapoorprognosis,anditseemsthatitmightberelatedtothedegreeofrightventricularhypertrophyaswellastothedegreeofrotation;in6ofthe8thetransitionzoneisbeyondV4,indicatingamarkeddegreeofclockwiserotation,althoughinonly1istheTwaveinversionbeyondV2.TheexplanationfortheqRpatternintherightchestleadsisstillunderdiscussion,buttheassocia-tionofthemarkedrotationwiththeappearanceoftheqRpatterninVIisconsistentwiththetheoryadvancedbyGoldberger(1945)andKossmanetal.(1948),andsupportedbyMcGregor(1950),thatthepatternofrightventricularhypertrophyisduetorotationoftheheartwithalmostcom-pletereversaloftheelectricalfieldsofthetwoventriclesinthethorax.Onepatient(Fig.7)whowasatfirstrejectedasapossiblecaseofFallot'stetralogyonaccountofapparentleftventricularpreponderance,furtherillustratesthispoint.OnpurelyclinicalgroundsthecasewasconsideredARNOLDWOODS200 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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P201 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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202ARNOLDWOODS

SUMMARYANDCONCLUSIONS

TABLEIX

ThemostconsistentfeaturescorrespondedcloselywiththosereportedbyDonzelotetal.(1951)andwerereversaloftheR/Sratio,markedrightaxisdeviation,delayoftheintrinsicdeflectioninVI,andabnormalityofthedifferentialindexbetweentheintrinsicdeflectionsofVIandV6(TableIX).Takingthesechangesinrathermoredetail,abnormallytallpointedPwaveswerefoundin35percent.Evidenceofmarkedrightaxisdeviationwaspresentinbothstandardandunipoplarlimbleadsin98percent.InaVRtherewasaprominentR,indicatingrightventricularhypertrophy,in68percent.ThedurationofQRSwasnormalin96percent.Therewere2casesofincomplete,butnocaseofcompleterightbundlebranchblock.Themostconsistentchangeswerefoundintherightchestlead,especiallythereversaloftheR/Sratio(98%)andthedelayoftheintrinsicdeflection(94%),withanabnormaldifferentialindexbetweentheintrinsicdeflectionsofV6andVI(96%).Swasprominentintheleftchestleads,butchangesinV6werelessstrikingthanthoseinVI.AqRpatterninVIwasnotcommon(15%),butitissuggestedthatitindicatesaseveredegreeofrightventricularhypertrophy,possiblycarryingwithitanunfavourableprognosis. on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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REFERENCES

Baker,C.,Brock,R.C.,Campbell,M;,andSuzman,S.(1949).Brit.HeartJ.,11,170.Brock,R.C.,andCampbell,M.(1950).BritHeartJ.,12,377.Donzelot,E.,Metianu,C.,Durand,M.,Cherchi,A.,andVlad,P.(1951).Arch.Mal.Ceur,44,97.Goldberger,E.(1949).UnipolarLeadElectrocardiography.2nd.ed.HenryKimpton,London.(1945).Amer.HeartJ.,30,341.andSchwartz,S.P.(1945).Amer.HeartJ.,29,62.Kossman,C.E.,Berger,A.R.,Brumlik,J.,andBriller,S.(1948).Amer.HeartJ.,35,309.Leatham,A.(1950).Brit.HeartJ.,12,213.McGregor,M.(1950).Brit.HeartJ.,12,351.Marquis,R.M.(1951).Brit.HeartJ.,13,89.Myers,G.B.,Klein,H.A.,andStofer,B.E.(1948).Amer.HeartJ.,35,1.Paul,O.,Myers,G.S.,andCampbell,J.A.(1951).Circulation,3,564.Sodi-Pallares,D.(1950).NuevasBasesdelaElectrocardiografia.I.N.C.Mexico.Sokolow,M.,andEdgar,A.L.(1950).Amer.HeartJ.,40,232.-,andLyon,T.P.(1949).Amer.HeartJ.,38,273.Wilson,F.N.,Barker,P.S.,Cotrim,N.,deOliveira,R.M.,Erlanger,H.,Hecht,H.,Johnston,F.D.,Kossman,C.E.,Rosenbaum,F.F.,andScarsi,R.,(1944).Amer.HeartJ.,27,19.203 on May 5, 2023 by guest. Protected by copyright.http://heart.bmj.com/Br Heart J: first published as 10.1136/hrt.14.2.193 on 1 April 1952. Dow

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