Dextropostion from Volvulus

An elderly was admitted due to abdominal pain and abdominal distention. Chest xray showed elevation of the left hemidiaphragm and plain abdominal films revealed dilated proximal bowel loops and the "coffee bean" sign. This was due volvulus and surgery was done.

Image 1 (xrays)




Something interesting was seen on the 12L.



The ECG showed reversal of R-wave progression pattern (decreasing amplitude from V1 to V6). The limb leads complexes looked normal (no signs of lead reversal leading us to think that this is dextrocardia and there is no dextrocardia in the chest xray). The direction of the apex in this case is a bit to the right due to the elevation of the left diaphragm and intestinal contents. Thus, this is dextroposition.

Ventricular orientation is best estimated from the precordial leads. Normal levocardia has a pattern of low voltage right chest leads with positive forces of higher amplitude in the mid and left chest lead. This pattern is reversed in dextrocardia. 

References:

- Bharate S and Lev M. Positional Variations of the Heart and Its Component Chambers. Circulation 1979:59:886-887

Khaity P and Marelli A. Clinical Use of Electrocardiophy in Adults with Congenital Heart Disease. Circulation 2007;116:2734-2746 

Walsh el al. Electrocaridography and Introduction to Electrophysiologic Techniques. Nada's Pediatric Cardiology 2006. Philadelphia PA

Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice (6th edition), Saunders 2008.

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