Right Axis Deviation: RVH

Report:

Sinus rhythm 92/min

Biatrial abnormality (LAA + RAA)

Right axis deviation +115o

Right bundle branch block

Inferior and anterior Q waves ? cause

Probable right ventricular hypertrophy

Comment:

The patient had very large dilated and hypertrophied right ventricle. There were no left-sided wall motion abnormalities or history suggestive of myocardial ischæmia. The Q waves were due to RVH alone, with, perhaps, a contribution from the right atrial enlargement35 in the case of V1 and V2. An LPHB could have contributed too, as well as accentuating the inferior Q waves.

However, LPHB cannot be diagnosed as the cause of RAD without clinical (not electrocardiographic) exclusion of RVH. The latter was certainly present in this unfortunate young man, precluded from heart transplantation by the coexistent cirrhosis. All the ECG findings can be ascribed to RVH: the Q waves, the RAA and even the LAA (sometimes due to right atrial enlargement), the RAD (commonest RVH expression in ECGs) and the precordial T wave inversion down to V5. The presence of RBBB tends to obscure the RVH, even with large V1 voltages; it matters less in this case.

Below (Fig 59a) is another trace, taken a year earlier. Lead V6 demonstrates the effect of frontal axis deviation on QRS morphology there with even slight vertical displacement.

Fig 59a.

Fig 60. 81 year old women with LBBB and rSr' pattern in V1. The trace was reported as sinus tachycardia with RBBB & LAHB by the computer, and with LBBB by a Cardiologist.