Friday, October 16, 2009

Severe Right Ventricular Hypertrophy

This 23 year old presented to the Emergency Department with pharyngitis, but also complained of dyspnea on exertion. This ECG was recorded:

The wide complex (QRS 155 ms) may distract your attention from the rhythm, which is simply sinus. There are massive S-waves in lateral leads, with an extreme right axis deviation (180 or -180, same thing). There are massive R' waves of RBBB in the right precordial leads. The combination of wide S-wave in V5 and V6, and large R' wave in lead V1 is diagnostic of RBBB. The precordial voltage is extreme, approximately 60 mm (6.0 mV) in V1.

So this is diagnostic of massive Right ventricular hypertrophy. One might be concerned for ischemia because of the large amount of ST depression and T wave inversion in V1-V3. Some discordant (in the opposite direction of a high voltage or bundle branch block QRS) ST depression and T inversion is usually found at baseline in RBBB, but this is more than usual. However, the voltage is also more than usual. The ratio of the ST depression to QRS voltage is about 4mm to 60 mm, or 0.067, which is normal. The troponin was mildly elevated due to demand ischemia of the RV.

Further history revealed congenital pulmonic stenosis which was dilated at age 7 days. The patient did not have further followup. Echocardiogram revealed an estimated peak systolic pulmonary pressure of 127 mmHg with RV enlargement and severe hypertrophy.


  1. I recently came accross your blog and have been reading along. I thought I would leave my first comment. I dont know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

    Doctor House
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  2. Dr. Smith -

    Is this similar to the equations you utilize for LVA and LBBB?

    I can see where 4 divided by 60 is 0.067 (are you comparing the J-point to the PQ segment)?

    What would be abnormal in this context?


  3. Tom,
    I'm comparing the voltage of the ST segment shift, in this case ST depression, to that of the R-wave height (amplitude). In RBBB and LBBB without ischemia, the ST segment will be opposite the QRS and will be proportional to the QRS amplitude. So with the high R-wave voltage, one would expect much ST depression. But how much? I don't think there is any data on this for RBBB. But for Left Bundle Branch Block, my data on 352 patients without MI who have LBBB (which, in contrast to RBBB, has a deep S-wave in V1-V4, not a tall R-wave) and no MI would have a mean ST/S ratio of 0.09, and a maximum of 0.19.

    Stephen W. Smith, MD

  4. Hello, I came across this while researching RVH. My question is what will be his treatment? Also I am curious as to what his outcome looks like? How will this impact his life? Thank you very much.

  5. In reply to above: I do not have enough information to know what the treatment will be. Furthermore, congenital heart disease is very specialized and I know relatively little about it. One might guess that the treatment would be to remove the obstruction in the pulmonary artery outflow tract, but this could lead to many bad unintended consequences including very elevated pulmonary capillary wedge pressure and pulmonary edema. Once there is such a profouond chronic adaptation to abnormal physiology, it becomes very difficult to correct. This is very difficult and specialized treatment.


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