THE CANADIAN MEDICAL ASSOCIATION

LSJOURNAL 2
VAOSOCRAIrnON JH IDECAILfE .1
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VE IBER 26, 1960

VOL. 83, NO. 22

CLINICAL SPATIAL VECTORCARDIOGRAPHY*

HARRY ABRANISON, MI.D. and C. R. BURTON, MI.D., M.R.C.P., F.R.C.P.[C], Toronto

INTSTNJTANEOUS
--T ELECTRICAL
RESULTANT

THERE IS NO DOUBT that the electrocardiogram has become firmly established in clinical medicine. Spatial vectorcardiography, on the other hand, is still in its infancy. Both deal with vectors. A vector is a mathematical symbol to denote a force. Such a force is represented by a straight line in the form of an arrow. The length of the arrow represents the magnitude of the force, while the positioin of the arrow in space indicates the direction of the force. Positivity and negativity are defined by an axis of reference. Mathematically, a multitude of instantaneous vectors may be represented by a single resultant vector. Thus, in the heart, the sum total of the electrical activity at any particular instant may be represented by a single resultant vector. This resultant vector changes from moment to moment during the electrical cycle of the heart, so that although ventricular depolarization is completed within a finite time period, it may be represented by an infinite number of resultant vectors. A line which joins the tips of these resultant vectors is known as a vector loop. Since such a loop is a record of the time-course of the infinite number of resultant vectors occurring during depolarization of the ventricles, it is known as the QRS loop. Similarly, that defining repolarization of the ventricles is known as the T loop. The P loop describes depolarization of the atria. Fig. 1 is a vector representation of the spread of depolarization throughout the ventricles of the heart. Each arrow shown represents one of the infinite number of electrical resultant vectors occurring during the process. The resultant vector is constantly changing in direction and magnitude. The dotted line outlining the ends of these resultant vectors is the vector loop. This loop has been inscribed in a clockwise direction. This meaiis that the initial forces of ventricular depolarization are directed superiorly to the patient's left. As the
*From the Departmen-t of Medicinie, University of Toronto, and the Cardiovascular Unit, Toronto General Hospital. This work was supported by the Ontario Heart Foundation and the National Health Grants Administration, Canada.

\I

I-

VECTOR LOOP

Fig. tion.

1.

A v-ector representation of ventricular depolariza-

process

continues, these forces increase in magnitude and become directed inferiorly. The terminal forces are directed inferiorly and to the right. If this loop were inscribed in a counterclockwise direction, the initial forces would be directed inferiorly to the right and the terminal ones superiorly to the patient's left. The QRS, T and P loops are spatial and do not lie in the same plane. The usual method of studying them consists in visualizing these loops from the front, top and side of the patient's body; hence the frontal, horizontal and sagittal plane projections of the spatial loops. These three plane projections comprise the vectorcardiogram (VCG). Over the years, there has been a great controversy concerning the relative merit of the different systems of electrode placement used to record the VCG. The tetrahedral system of Wilson and the cube system of Grishman have enjoyed considerable popularity. In 1956, Ernest Frank of the University of Pennsylvania described a precordial lead system which he showed experimentally to be superior to others. 2 We have adopted the Frank system in laboratory, and the following briefly describes the technique involved. Basically, any system of electrode placement in vectorcardiography seeks to achieve one aim, i.e. to determine all the electrical activity arising in the heart and to divide this into three different components acting at right angles to one another. Commonly, these are referred to as the X component acting transversely in a horizontal direction,
1

our

1131

1132 ABRAMSON AND BuRrON: SPATIAL VECTORCARDIOGRAPHY

CanaO.M.6 . 83

SPACEMIC
/ THORAX,

ANATOMIC

1A
450
l.
Fig. 2

c4.59R

the plates. The beam deflection may be represented by a vector. The length of this vector will vary directly with the magnitude of the potential difference. Similarly, the electron beam is deflected in a vertical direction if a potential difference acts across the vertical plates. This deflection may be \represented by another vector. If both potentials act simultaneously, then the electron beam is deflected not horizontally or vertically but diagonally. 2 The vector representing this third deflection is the trigonometric resultant of the horizontal and vertical vectors. Thus the beam is under the influence of electromotive forces acting at right angles to one another.
ANATOMIC.
SPPCE

the Y component acting vertically, and the Z component acting in an anteroposterior direction. The Frank system of electrode placement determines X, Y and Z by means of seven electrodes, one on the back of the neck in the midline, one on the left leg, and five on the chest. The right leg is grounded. All chest electrodes are placed at the level of the fifth interspace in the midsternal line. Figs. 2, 3 and 4 describe the electrode placement and the circuitry used to determine X, Y and Z. Electrodes are placed in the midstemal line (E), in the middle of the back (M) and in the left and right midaxillary lines (A and I respectively). A fifth electrode (C) is placed on the left precordium so that a line joining (C) to the centre of the thorax (0) exactly bisects the 900 angle formed by lines OA and OE. The position of C is determined by means of a protractor, for electrode placement must be accurate if this system is to be valid. A cathode ray oscilloscope is used to obtain a vector loop. If a potential difference acts across the horizontal plates of an oscilloscope, then the beam of electrons is influenced by these plates only and is deflected towards or away from them, depending on the relative positivity or negativity of
ANATOMIC

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This principle is utilized in obtaining the frontal, horizontal and sagittal plane projections of the . \4S x 1 sA \ 45S/ / vectorcardiogram. In order to obtain the frontal 45\ \ /plane projection or view of the vector loops ob) ZC tained from the front of the patient's body, Vx, the c potential acting in a horizontal direction, is thrown of iacross the horizontal plates of a cathode ray oscil. i N ' tloscope. Simultaneously, Vy, acting vertically, is CY thrown across the vertical plates. These potentials {n^ te I Xi vary throughout the heart cycle but, at any particular instant, the beam of electrons is influenced Fig. 3
m

Canad. M. A. J. Nov. 26, 1960, vol. 83

ABRAMSON

AND

BURTON: SPATIAL VECTORCARDIOGRAPHY 1133

by both Vx and V,. to produce a resultant deflection which as it changes from moment to moment outlines the frontal plane projection of the vectorcardiogram. By using different combinations of Vx, VY and V, across the opposing plates of the oscilloscope, one obtains the horizontal and sagittal
projections as well. Vx and

LEAD aVR

TYF An aV a

V7,

give the horizontal

300

_,o 30

LEAD

projections;

records are obtained by photographing the loops. The Einthoven triangle, a fundamental concept of electrocardiography, is based on the assumption that the heart is at the geometric centre of an equilateral triangle formed by the right and left shoulders and left leg. It describes the direction taken by the axes of the standard and unipolar limb leads and defines, as well, arbitrary positivity and negativity. This information may be simplified by transposing it to the multiaxial scale depicted in Fig. 5. This shows more clearly than does the Einthoven triangle the actual direction taken by the axes of the various leads of standard electrocardiography. It may be seen that the positive lead 1 axis acts in a horizontal direction to the patient's left, lead aVF acts vertically and inferiorly. Leads 2 and 3 each act 300 to the vertical, lead aVL 300 superiorly to lead 1 and lead aVR 300 superiorly to the horizontal direction but to the patient's right. Superimposed on this system of lead axes in Fig. 5 is a single vector R, acting +40 to the horizontal. The sole purpose of this system of leads is to determine R as accurately as possible. Unfortunately all six leads cannot do so to the same extent. The electrical force represented by R will cause maximal deflections only in those leads whose axes are roughly parallel to the direction of R and minimal deflections in those leads whose axes lie at right angles to R. An arbitrary principle of electrocardiography is that an electrical force will be registered as an upright or positive deflection if the force is directed towards the exploring electrode in a unipolar lead or towards the positive electrode in a bipolar lead. Thus, in the example cited, the force represented by vector R will register maximally in leads 2 and aVR and minimally in leads aVL and 3. The deflection in lead 2 will be positive and that in lead aVR negative. The galvanometer deflections of the standard electrocardiogram (ECG) are obtained by superimposing the system of lead axes shown in Fig. 5 upon the frontal plane projection of the spatial vectorcardiogram (VCG). Thus the relationship between the ECG and the VCG is a very close one, for the ECG is indeed derived from the VCG. Fig. 6 demonstrates this relationship. It is the frontal plane projection of the VCG of a patient with an atrial septal defect. The lead axes of the standard ECG have been superimposed. There is a time interval of 0.004 second between each dewdrop-shaped dot in the QRS loop of the VCG. Since
each dot

V7 and V! the sagittal.

Permanent
30'0

R
300

LEAD 3 LEAD aVF

LEAD 2

Fig. 5.

Simplifled Einthoven triangle.

T loops

are superimposed one upon the other. The significance of the various positive and negative deflections in the ECG now becomes apparent. Lead aVR shows a deep Q or negative deflection and a small R or positive deflection because most of the electrical forces in the heart are directed away from the direction of lead aVR. Only the terminal forces as described by the terminal portion of the QRS loop are directed towards aVR, hence the late positive deflection. The initial forces as described by the initial portion of the QRS loop are directed away from the lead 3 axis, hence an initial negative deflection or Q wave; and as the forces change direction, become directed towards lead 3 and increase in magnitude, this change is manifested by a tall positive deflection or R wave following the Q wave. Similarly leads 1 and aVL show initial positive R waves and secondary negative S waves. The initial Q wave in lead aVF is greater than that in lead 2 and the Q wave in lead 3 is greater than the one in lead aVF, for the initial part of the loop is heading approximately 1800 away from lead 3 whereas it is only 1200 away from the axis of lead 2. Since the terminal part of

tion,

thins out in the direction of loop inscripone can tell that the QRS loop has been inscribed in a clockwise direction. The smaller P and

Fig. 6.-Frontal plane projection wvith corresponding ECG.

1134 ABRAMSON

AND

BURTON: SPATIAL VECTORCARDIOGRAPHY

Canad. M. A. J. Nov. 26, 1960, vol. 83

the QRS loop is heading away from lead 2, this lead shows a secondary negative deflection or S wave which is barely perceptible in lead aVF and absent in lead 3. The most upright P and T waves are present in lead 2, for the P and T loops of the VCG are directed along the axis of this lead. Lead aVR has an inverted P and T wave, for this lead axis is directed 1500 away from the axes of these two loops. Thus the six standard and unipolar limb leads may be derived from the frontal plane projection of the VCG, and similarly a rough frontal plane projection of the P, QRS and T loop may be sketched from these leads. The vectorcardiogram shown in Fig. 7 a, b and c is that of a 27-year-old subject with a normal heart. In each plane projection one may see a small P loop, larger QRS loop and intermediate-sized T loop. In the frontal plane the QRS loop has been inscribed in a clockwise direction. It is directed inferiorly and to the patient's left. Normally in this plane, the QRS loop may be inscribed either clockwise or counterclockwise. It may even have a figure-of-eight configuration. The normal QRS loop tends to assume the shape of a flat disc, lying more or less in the plane of the interventricular septum. Thus we view it almost on edge when studying it from the front of the patient. The P and T loops are both directed inferiorly and to the left. In the horizontal plane projection the QRS loop is always inscribed in a counterclockwise direction. The loop is directed first anteriorly and then posteriorly because of early septal depolarization and subsequent depolarization of the free wall of the left ventricle. Lead V1 of the electrocardiogram shows a small initial R wave because the QRS loop initially is directed towards this electrode. The deep late S wave is due to most of the QRS loop heading away from the V1 electrode. Left lateral precordial leads usually show an initial Q wave for the same reason. The QRS loop at first is heading away from the V,-6 position. As the terminal part of the loop heads towards these electrodes, a tall R deflection results. The T loop is directed anteriorly and to the left. The P loop is also directed to the left; it may be anterior, but never posterior. The left sagittal plane projection always shows counterclockwise inscription of the QRS loop in the normal heart. As in the horizontal plane, the QRS loop is directed first anteriorly and then posteriorly. The anterior position of the T loop is typical. The P loop is directed inferiorly. Toscano-Barbosa, Brandenburg and Burchell3 of the Mayo Clinic first pointed out in 1956 that vectorcardiography assists in the differentiation of different types of atrial septal defects. The ostium secundum defect is usually centrally situated and may be corrected under hypothermia alone. The ostium primum defect, whether single or associated with a complete atrioventricularis communis defect, is situated in relation to the A-V valves and requires the use of a pump-oxygenator for correction. Thus preoperative differentiation of

Fig. 7 a, b, c.-Normal vectorcardiogram.

these two types of defects is important for proper management. The QRS loop in the secundum defect is situated inferiorly, whereas that in the ostium primum defect is situated superiorly. This difference is especially apparent in the frontal plane projection.

Fig. 8.-(a^) Ostium secundum defect, frontal plane. (b) Ostium primum defect, frontal plane.

Fig. 8a shows the frontal plane projection of the VCG of a patient with surgically proved ostium secundum defect. The QRS loop is situated below the isoelectric point and is inscribed in a clockwise fashion. The QRS loop shown in Fig. 8b is that of a patient with surgically proved ostium primum defect. It is situated above the isoelectric point and is inscribed in a counterclockwise direction. The primum defect somehow has lifted the loop. It is generally felt that this specific loop configuration is due to a disturbance in conduction resulting from the very low position of the defect. Different abnormalities of right ventricular depolarization may produce practically identical ECG's and yet distinctly different VCG's. Figs. 9 and 10 show the precordial leads of two electrocardiograms. In each the QRS duration is 0.10

Nov. 26, 1960, vol. 83

Canad. M. A. J.

ABRANISON AND BURTON: SPATIAL,

VECTOR{:ARDIOGRAPHY

1135

V2

VW2e4
Fig. 9

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two abnormalities involving the right side of the lheart can be differentiated immediately by means of the vectorcardiogram. It is not yet clear whether the vectoreardiogram can diagnose myocardial infarction not apparent in the standard electrocardiogram. Milnor feels that the vectorcardiogram is of help in cases of old infarction showing a small Q wave in lead t3 or diminished R waves in the precordial leads.4 It mutst be remembered that the abnormal Q wave, so important in the electrocardiographic diagnosis of infarction, is a manifestation of the initial segment of the QRS loop. Abnormalities of the terminatl segment of the QRS loop result in barely perceptible electrocardiographic changes. It may wvell be that the VCG is superior to the ECG in diagnosing myocardial infarction. Certainly more work remains to be done in this important field.
SUNINIARY Some of the basic priniciples of spatial vectorcardiography have been reviewed aand the fact that the stacndard electrocardiogram is derived from this more basic study has been emphasized. Both, in turn, are mianifestations of the same electrical phenomena arising within the heart. Although it is too early as yet to assess its ultimate value as a diagnostic aid, there cain be nio doubt thalt spatial vectorcardiography has a definite place in clinical medicine.
Figs. 2, 3 and 4 are reproduced from Circulation, 13: 737, 1956, by kind permission of the American Heart Association, Inc., and the auithor, Dr. Ernest Frank.
REFERE N CES

V1

V.4 h. .2
Fig. 10

seoond. Because of the presence of an RSR pattern in lead V1 and a wide slurred S in VG;, most cardiologists would interpret this pattern as that of incomplete right bundle branch block. On viewing the horizontal plane projection of the VCG in each instance, one can immediately see that although the precordial leads are almost identical, these

1. FRANK, E.: Circulation, 13: 737, 1956. 2. Idem: Ibid., 10: 101, 1954. 3. TOSCANO-BARBOSA, _., BRANDENBURG, R. 0. AND BURCIIELL, H. B.: Proc. Staff Meet. Mla lio Clinu., 31: 513, 1956. 4. MILNOR, W. R.: Pr oyr) Cardiorase. Dis., 1: 175, 1958.

Fig. 11.-( a) Incomrplete right bundle branch block, horizontal pla.ne. (b) Right ventricular di.stolic overload, horizontal plane.

DEATH WATCH

leads have been derived from two quite dissimilar QRS loops. In Fig. lla the QRS loop shows normal counterclockwise inscription with a marked terminal delay. The initial one-inch segment of loop has been inscribed in 0.024 second, the terminal oneinch segment in 0.032 second. Such a pattern is indicative of delayed right ventricular depolarization. Fig. llb shows a horizontal plane projection in which the QRS loop is inscribed in a clockwise fashion as in right ventricular hypertrophy. There is no terminal delay. Both initial and terminal oneinch segments of the QRS loop have been inscribed in 0.020 second. Although the electrocardiogram appears to be that of incomplete right bundle branch block, these vector studies show clearly that this electrocardiogram is really a manifestation of right ventricular diastolic overload and not of delayed right ventricular depolarization. Thus these

Psychic trauma has cropped up again as a medico-legal entity . . . in the recently raised question: Is a fatal heart attack caused by psychic trauma "accidental"? Yes, says the Texas Supreme Court, basing its opinion on expert medical testimony to the effect that a cerebral arteriothroimbosis might be precipitated by emotional stress and strain. The decision resulted in payment of double indemnity by two insuLrance companies to the beneficiaries of a 44year-old accountant who died of cerebral thrombosis more than aimonth after witnessing a serious fire in his office. Although the arteriosclerosis found in his brain at autopsy was insufficient to have caused the thrombosis, the experts said hisi nervousness and excitement on seeing the fire could have produced damage to cell tissue not only in the brain but in. other organs, too. The court, therefore, saw no difference between this case and one of drowning or asphyxiation, where the "external and violenft" force enters through the nose or mouth rather than the eyes, and causes dealth by injuring other organs.MHedical News, September 28, 1960.