Section 10 Miscellaneous

The athletic heart

Acute pulmonary embolus (PE)

Cardiac amyloidosis

Arrhythmogenic right ventricular dysplasia (ARVD)

Left ventricular aneurysm

Acute pericarditis

Pericardial effusion

Pericardial effusion with electrical alternans

Wolff-Parkinson-White syndrome (1) (ventricular pre-excitation)

Wolff-Parkinson-White syndrome (2)

Lown-Ganong-Levine syndrome

Congenital long QT syndrome (LQTS)

Dextrocardia

Auxiliary (heterotopic or ‘piggyback’) heart transplant

Case 89 A 21-year-old male pilot

The athletic heart

Young athletic hearts may show the following features:

• ‘early repolarisation’:

– prominent J waves best seen in leads V5-6

– concave upward, minimally elevated ST segments

• relatively tall, frequently symmetrical T waves (T waves are usually asymmetrical)

• occasionally inverted T waves laterally

• prominent mid-precordial U waves

• prominent, but narrow, q waves in the left precordial leads

• sinus bradycardia

• persistent juvenile pattern – T wave inversion V1-3

• left ventricular hypertrophy voltage criteria.

Features of this ECG

• Sinus arrhythmia, rate 54 b.p.m., normal QRS axis

• Features of an athletic heart (Fig. 89.1):

– narrow q waves

– early repolarisation V2-6

– symmetrical T waves

– U waves

– large voltage deflections

Fig. 89.1 Athletic heart.

Clinical Note

This young man was a cross country runner and physical education instructor who had an ECG as part of his recreational pilot’s medal.

An echocardiogram showed concentric left ventricular hypertrophy.

Case 90 A 60-year-old man with oesophageal cancer develops dyspnoea and hypotension

Acute pulmonary embolus (PE)

In massive pulmonary embolus the follo changes may be seen:

• an S1 Q3 T3 pattern

• sinus tachycardia

• incomplete or complete RBBB

• T wave inversion in leads V1-3.

Other changes seen:

• prominent R wave in lead aVR

• prominent S wave in lead V6

• low amplitude deflections.

Features of this ECG

• Sinus tachycardia, 102 b.p.m., superior axis -90° (or +270°)

• Features of acute pulmonary embolus:

– prominent S wave in lead I (Fig. 90.1)

– Q wave and T wave changes in lead III (Fig. 90.2)

– incomplete RBBB pattern (Fig. 90.3)

– T wave inversion in the right-sided chest leads (Fig. 90.3)

– sinus tachycardia

Fig. 90.1 Lead I.

Fig. 90.2 Lead III.

Fig. 90.3 Lead V1.

Clinical Note

This man had a massive pulmonary embolus and died the following day. His CT pulmonary angiogram (CTPA; Fig. 90.4) shows the lower oesophageal tumour, thrombus in the pulmonary arteries and pulmonary infarction.

Fig. 90.4 CTPA. Lower oesophageal tumour (A), thrombus in a branch of the right pulmonary artery (B) and pulmonary infarction (C).

Causes of an S1 Q3 T3 pattern

→ Normal variant

→ Acute pulmonary embolus

→ Left posterior hemiblock

Case 91 A 72-year-old man with multiple myeloma

Cardiac amyloidosis

• Conduction blocks.

• Anteroseptal MI pattern (absent r waves in V1-3).

• Low voltage QRS and T waves.

Features of this ECG

• Sinus bradycardia, 55 b.p.m., left axis deviation (-70°)

• Prolonged QTc (530 ms)

• Features of amyloidosis:

– low voltage QRS and T waves

– left bundle branch block (Fig. 91.1)

– left anterior hemiblock (Fig. 91.2)

Fig. 91.1 Left bundle branch block (QRS duration 130 ms, no secondary R wave in V1, no Q waves in the lateral leads, secondary T wave changes).

Fig. 91.2 Left anterior hemiblock (left axis deviation, rS complexes in the inferior leads).

Clinical Note

This elderly man had AL type amyloidosis. An echocardiogram showed severely impaired LV function with a speckled myocardium typical of cardiac amyloidosis.

Case 92 A 35-year-old male presents following a collapse whilst running

Arrhythmogenic right ventricular dysplasia (ARVD)

• Complete or incomplete right bundle branch block (RBBB) pattern.

• An epsilon wave (a wave immediately after the QRS, usually best seen in V1).

• T wave inversion in the right precordial leads.

Features of this ECG

• Sinus rhythm, 66 b.p.m., right QRS axis deviation (+120°)

• Features of ARVD:

– incomplete RBBB pattern, QRS duration < 120 ms except for in V1 where the epsilon wave gives the appearance of complete RBBB (Fig. 92.1)

– T wave inversion in V1-4 (Fig. 92.2).

Fig. 92.1 Lead V1.

Fig. 92.2 Lead V4.

Clinical Note

An echocardiogram showed a mildly dilated right ventricle with akinetic regions. Invasive electrophysiology (EP) studies demonstrated inducible VT. The patient was treated with sotalol.

Case 93 An 83-year-old man with a history of an extensive anterior MI 8 years ago

Left ventricular aneurysm

• Persistence of Q waves and raised ST segments for more than 3 months following an acute myocardial infarction.

Features of this ECG

• Sinus rhythm, 60 b.p.m., left axis deviation (−30°)

• Features of anterior left ventricular aneurysm:

– deep Q waves and ST elevation in the anterior leads (Fig. 93.1)

• Features of left anterior hemiblock (Fig. 93.2):

– left axis deviation

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Systemic disorders and drug effects
2. Hypertrophy patterns
3. Bundle branch block
4. Ventricular rhythms

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree