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A forty-year-old woman with a history of a cardiac operation at age 5 years.

ECG of the Month Presentation is on p. 196

DIAGNOSIS: Sinus tachycardia, voltage criteria for left ventricular hypertrophy (LVH) with QRS prolongation (incomplete left bundle branch block) and repolarization change.

There is a sinus P wave in front of each QRS, and the rate is 122 beats/min. The QRS voltage is large and meets many criteria for left ventricular hypertrophy: RI > 13 mm (1.3 mV); RaVF > 19 mm; SaVR > 14 mm; SV1 > 24 mm; SV2 > 30 mm; RV6 > 26 mm; RV6 > RV5; SV1 + RV5 or RV6 > 35 mm; SV2 + RV5 or RV6 > 45 mm; RaVL + SV3 > 20 mm in a woman. (1) In addition, there are two non-voltage criteria for LVH: QRS duration = 0.11 s and typical repolarization changes: J-point depression with a downsloping ST segment into an inverted T wave and a more rapid upslope back to the baseline. The prolonged QRS duration and repolarization changes are also typical of incomplete left bundle branch block (ILBBB). LVH is present in most patients with complete LBBB, (2,3) and probably in most with ILBBB.

The patient underwent aortic valvotomy at age 5 to relieve congenital stenosis. Although different valvular morphologies can result in aortic stenosis, when hemodynamically significant stenosis is present in infancy or early childhood the valve is usually unicuspid/unicommissural. Aortic valvotomy can greatly reduce the left ventricular outflow obstruction in such patients, but the majority eventually need reoperation. This usually means aortic valve replacement. This woman now has severe aortic stenosis and regurgitation with not only left but also right ventricular failure, which is a late development with pure aortic valve disease. She needs aortic valve replacement. Unfortunately having one severe disease does not preclude another, and her operative course will be complicated by multiple sclerosis which she developed some 12 years ago.

D. Luke Glancy, MD; Koteswara R. Pothineni, MD

REFERENCES

(1.) Milliken JA, Macfarlane PW, Lawrie TDV. Enlargement and hypertrophy. In: Macfarlane PW, Lawrie TDV. Comprehensive Electrocardiology: Theory and Practice in Health and Disease. New York: Pergamon Press;1989;1:631-670.

(2.) Lev M, Unger PN, Rosen KM, et al. The anatomic substrate of complete left bundle branch block. Circulation. 1974;50:479-486.

(3.) Scott RC, Norris RJ. Electrocardiographic-pathologic correlation study of left ventricular hypertrophy in the presence of left bundle-branch block. Circulation. 1959;20:766-767

Dr. Glancy is a professor and Dr. Pothineni is a fellow in the Sections of Cardiology, Departments of Medicine, Louisiana State University Health Sciences Center and the Interim LSU Public Hospital, New Orleans.

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Title Annotation:ECG of the Month
Author:Glancy, D. Luke; Pothineni, Koteswara R.
Publication:The Journal of the Louisiana State Medical Society
Article Type:Clinical report
Date:Jul 1, 2015
Words:417
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