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Revealing the Truth of Severe Right Axis Deviation Due to Large Hiatal Hernia

  • Yi Li
    Affiliations
    Division of Cardiology, Department of Internal Medicine. Zhongnan Hospital of Wuhan University, Institute of Myocardial Injury and Repair, Wuhan University, Wuhan, China
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  • Tong Liu
    Affiliations
    Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
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  • Zhibing Lu
    Correspondence
    Requests for reprint should be addressed to Zhibing Lu, PhD. Division of Cardiology, Department of Internal Medicine, Zhongnan Hospital of Wuhan University, Institute of Myocardial Injury and Repair, Wuhan University, Wuhan 430030, PR China
    Affiliations
    Division of Cardiology, Department of Internal Medicine. Zhongnan Hospital of Wuhan University, Institute of Myocardial Injury and Repair, Wuhan University, Wuhan, China
    Search for articles by this author
      To the Editor:
      Professor Tsai et al
      • Tsai C
      • Tu Y
      • Dickey S
      • et al.
      Large hiatal hernia manifesting as dextrocardia on electrocardiogram.
      shared a meaningful and well-documented case of a patient's electrocardiogram (ECG) manifesting as dextrocardia due to a large hiatal hernia and that completely resolved after surgery. The authors attributed the “severe right axis deviation” and “P and T wave inverted in lead I and aVL” in initial ECG to the dextrocardia. However, based on the findings in this article, we believe that the ECG manifestation is due to leads misplacement; in other words, electrodes connected left upper limb and right upper limb were mistakenly exchanged. Scrutinizing the 2 ECGs, we can uncover the following findings (Figure): 1) lead I in initial ECG (ECG 1) = - lead I in postoperative ECG (ECG 2); 2) lead IIECG 1 = lead IIIECG 2 and lead IIIECG 1 = lead IIECG 2; 3) aVRECG 1 = aVLECG 2 and aVLECG 1 = aVRECG 2. For the limb leads, the findings in preoperative ECG indicated either mirror-image dextrocardia or lead misplacement of left and right upper limb, and the former can be excluded by the computed tomography result and the ECG manifestation after surgery.
      Figure
      FigureThe morphology of QRS complex in any 2 linked boxes were similar, which indicated leads misplacement between left and right upper limbs.
      Unlike the mirror-image dextrocardia or complex transposition of great artery, mass compression due to large hiatal hernia, left pneumothorax often manifested as dextroposition or dextroversion with situs solitus,
      • Perloff JK
      The cardiac malpositions.
      which also confirmed by the computed tomography images. Thus, atrial depolarization proceeds normally from a right sinus node even in right thoracic cavity, and the P-wave axis is always normal or mild right deviation unless combined with ectopic atrial arrhythmia.
      • Momma K
      • Linde LM
      Cardiac rhythms in dextrocardia.

      References

        • Tsai C
        • Tu Y
        • Dickey S
        • et al.
        Large hiatal hernia manifesting as dextrocardia on electrocardiogram.
        Am J Med. 2022; 135: 57-59
        • Perloff JK
        The cardiac malpositions.
        Am J Cardiol. 2011; 108: 1352-1361
        • Momma K
        • Linde LM
        Cardiac rhythms in dextrocardia.
        Am J Cardiol. 1970; 25: 420-427