RVH. Type 1. Case 2

Patient. 35 year old male, weigh 380 lbs with 5' 10" height, was admitted with history of progressive dyspnea. He was known to have obstructive sleep apnea, hypoventilation and cor pulmonale. Chest CT scan did not revealed pattern of pulmonary emboli. Chest X Ray suggested pulmonary congestion. Echocardiogram showed pattern of LVH with good systolic function. There was no statement on the RV. Patient had severe schizophrenia and has not been able to follow appropriate treatment program.

Because of the dominant LV mass influencing the QRS force and direction, the RVH has to be atleast moderate to change these QRS force and direction.

Type 1. Typical RVH pattern with strong RV anterior and rightward QRS vector. The RV mass is approaching LV mass as in some congenital heart diseases, primary pulmonary hypertension.
  1. Tall R in V1 (V3R, V1-V2), due to increase RV force and direction towards anterior and rightward. qR pattern suggests more severe RVH.
  2. rS pattern in "LV lead" (I, aVL, V5-V6). The change in I and aVL results in RAD on frontal plane, while change in V4-V6 results in reversal of R wave progression of the precordial leads.
  3. "Secondary ST T change" in V1 (V3R, V1-V2). This abnormality may help differentiate from some other conditions with prominent R wave in V1 or R/S ratio >1

Type 2. Found in patient with lung condition creates hyperinflate lung and changing heart position within the chest, COPD, emphysema without corpulmonale.
  1. RAD
  2. Deep S in lateral precordial lead.
  3. S1Q3T3 pattern (rS or RS in lead I, abnormal Q in III. and inverted T in inferior leads.
  4. RA abnormality helps this diagnosis.

Type 3. Found in RV volume overload like ASD.
  1. rSr' in V1
  2. Persistent S in lateral precordial leads, V5-V6.

Type 4. Acute RV pressure overload as in acute pulmonary embolism.
  1. QR or qR in RV lead.
  2. S1Q3T3 (rS or RS in lead I, abnormal Q in III, and inverted T in inferior leads.
  3. STT abnormality in V1-V3 (ST depression and/ or T inversion).
  4. Incomplete or complete RBBB.

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