DR.G .

BALAJI
PROF.DR.S.RAMASAMYS
UNIT
ECG shows
Rate - 70/min

Rhythm - Sinus rhythm; Regular

P Wave
Duration - 0.04 Sec.
Amplitude - 0.04 Sec.
Morphology Negative in I, II ,a VL
Positive in a VR
 QRS complex
Duration - 0.08 Sec.
Axis - approx. 130 degrees (RAD)
Poor R wave progression
Ventricular activation time - <0.04
sec

ST segment - mild ST elevation II, III, a

VF

T wave - Negative in I, a VL
 ECG findings is classical of
SITUS INVERSUS DEXTROCARDIA
NEGATIVE P waves
QRS waves
T waves
in conventionally recorded
LEAD I

Right Axis Deviation

POSITIVE P waves in LEAD III, a VF

 CONTINUES
UPRIGHT EQUIPHASIC P waves in aVR

QRSComplex dominantly positive in

LEAD III & a VF & a VR. Dominantly
negative in I & a VL

ReversedQRS pattern, tallest in lead V1,

and diminishing progressively towards
lead V6
 CARDIAC MALPOSITION

Prevalence-0.10 per 1000 live births.

It is defined as an abnormal intra

thoracic location of the heart or a
location that is abnormal (inappropriate)
relative to the position of the abdominal
viscera.
 Ventricular Loop : Right or Left bend
(loop)that forms in the straight heart tube of
the embryo.

d-loop: Normal right ward (dextro) bend

in the embryonic heart tube. This designation
as applied to the developed heart indicates that
the sinus/inflow portion of the morphologic
right ventricle lies to the right of the
morphologic left ventricle.
 l-loop: A leftward (levo) bend in the
embryonic heart tube. The l-loop designation
as applied to the developed heart indicates that
sinus or inflow portion of the morphological
right ventricle lies to the left of the
morphological left ventricle .

Concordant Loop: It refers to a ventricular

loop that agrees with the visceroatrial situs.
d-loop: situs solitus
l-loop: situs inversus.
 BASIC CARDIAC MALPOSITION

BILATERAL ASYMMETRY:
1. Visceroatrial situs inversus with
dextrocardia
2. Visceroatrial situs solitus with
dextrocardia
3. Visceroatrial situs inversus with
levocardia
BILATERAL SYMMETRY:
1. Visceral heterotaxy with right
isomerism
2. Visceral heterotaxy with left isomerism
 SITUS SOLITUS
The normal position of the heart and
viscera.
The base to a apex axis which points to
the left because the straight heart tube of
the embryo initially bends to the right (d-
loop) and then pivots to the left until the
ventricular portion comes to occupy its
normal left thoracic position.
 BILATERAL ASYMMETRY
SITUS INVERSUS WITH DEXTROCARDIA:

1. Incidence is one in 8000 births.

2. Heart, thoracic and abdominal viscera are

mirror images of normal situs.

3. Incidence of congenital heart disease is

5%
4. Heart is right sided: Right hemi
diaphragm lower than the left.

5. Anatomical right ventricle lies to the left

of the anatomical left ventricle (l-loop)
which is normal for situs inversus.
ECG FEATURES:
1.Inverted P-wave, negative QRS
complex and inverted T-wave in lead I,
2.Reversal of the QRS pattern in
lead aVR and aVL.
3.Reversal of corresponding right
and left precordial leads.
(atrial depolarisation from left sinus node)
SITUS SOLITUS WITH DEXTROCARDIA:
1. Lungs and abdominal viscera are situs solitus,
but the heart is on the right side
(dextrocardia)
2. Incidence of the congenital heart
disease is around 98%. Most common
is TGA (congenitally corrected). Others are
shunt lesions.
3. Ascending aorta and aortic knuckle occupy
their normal position and descending aorta
runs its normal course along the left.
4. The base to the apex axis points to the right
and the right hemi diaphragm is lower than
the left.
5. Anatomical right ventricle lies to the right of
the anatomical left ventricle(d-loop). Heart
tube is initially bent in a rightward direction
and but then fail to the pivot into the left
chest.
ECG FEATURES:
1.Upright P-wave in lead I.
2. Normal P-wave pattern in leads
aVR and aVL (atrial situs solitus).
3.Major precordial QRS voltage lies
in the right hemi thorax .
(atrial depolarisation from normal right
sinus node)
SITUS INVERSUS WITH LEVO CARDIA:
1. Situs inversus of thoracic and abdominal
viscera in the presence of left thoracic heart
(levo cardia)
2. Incidence of cyanotic congenital
heart disease is 100%
3. Left hemi diaphragm is lower than the right
because apex is on the left.
4. Embryonic l-loop which is concordant for situs
inversus fails to pivot into the right side of the
chest
or embryonic d-loop which is discordant for
situs inversus fails to pivot into the left side
ECG FEATURES:

1.Inverted P-wave in lead I, a VL.

2.upright P-wave in lead a VR (atrial situs

inversus).

3. The major precordial QRS complex resides

in the left of the midline.
 BILATERAL SYMMETRY
HETEROTAXY : just means different arrangement.
ISOMERISM : Refers to bilateral symmetry.
Visceral heterotaxy occurs in 0.8% of cases of
congenital heart diseases.

In right isomerism (Asplenia) and left isomerism

(Polysplenia), the liver is typically transverse (B/L
symmetric) and SVC are typically bilateral i.e, there is
no perfect rigid relationship.
 Bronchus, lung, atrial appendages
relationship is strong but not invariably
concordant.
There is a consistent relationship
relationship that exists between the type of
isomerism and the type of congenital heart
disease.

VISCERAL HETEROTAXY
1.Right Isomerism
2.Left isomerism
DEXTROCARDIA d/t TECHNICAL FAULT:
1.Due to interchanging of a VR and a VL.
2.ECG shows negative P wave, negative
QRS complex, negative T wave in lead I.
QRS progression is
3.But the
normal.