Emphysema: Left Axis Deviation

Report:

Sinus tachycardia

Right atrial abnormality

Left axis deviation –40o

Possible old anterior infarction

Suggestive of emphysema

Comment:

Characteristically, S2 > S3 in LAD due to emphysema vis à vis LAHB. Some argue this is not a true LAD but an “axis illusion” due to cardiac position and stretch in an overexpanded chest.

The precordial progression suggests an old anterior infarction, but there was no clinical evidence for this; emphysema alone can account for the QS complexes. She had incurable, crippling COAD and was extubated and allowed to die.

Below is a similar ECG (Fig 77a), from a 48 year old lady in similar circumstances. Her LAD could be from inferior MI, but wasn’t. There is small voltage in the frontal leads and poor R wave progression in the precordial ones. Like in the previous example, the QRS is typically narrow, although no actual criteria exist for abnormally short QRS. She also has a right ventricular impulse distorting ST segment in V3 (“electromechanical association”, v. Case 72).

77a. There is a mechanical RV impulse distorting V3. 78. 67 year old lady with single-vessel coronary disease, discovered to have a shunt during bypass surgery