complete transposition of the great vessels · mean manifest electrical axis. the mean qrs axis in...

Complete Transposition of the Great VesselsII. An Electrocardiographic Analysis

By LARRY P. ELLIOTT, M.D., RAY C. ANDERSON, M.D., NAIP TUNA, M.D.,PAUL ADAMS, JR., M.D., AND HENRY N. NEUFELD, M.D.

THE electrocardiographic patterns in in-fants with complete transposition of the

great vessels are neither so uniform nor sodiagnostic as those in sonie other types ofcongenital cardiac disease. Zuckermann,1 Sodi-Pallares,2 and their respective associates haveindicated that certain T-wave configurationsmay contribute to the diagnosis of completetransposition of the great vessels. Generally,however, the electrocardiogram is consideredto be nonspecific.

Several other investigators3-5 have relateda defect in the ventricular septum with (1)the degree of axis deviation, (2) the configu-ration or height of the R wave in lead VI,(3) the per cent R of RS in leads V4n andV1, and (4) the height of the RS voltage inthe midprecordial leads. These studies, how-ever, have directed little or no attention tothe possible electrocardiographic influences ofthe size of the ventricular septal defect, norhave they taken into account additional formsof communication that may be present-suchas a large patent ductus arteriosus.The difficulty in evaluating electrocardio-

graphic data in patients with complete trans-position of the great vessels has stemmed fromseveral factors. The comnplex assortment ofmalformations designated as "complete trans-position of the great vessels " is bound to haveresulted in confusion; thus, some conditionsthat include transposed great vessels are to

Fromi the Departments of Pediatrics and Medicine,University of Minnesota, Minneapolis, and the Depart-ment of Pathology, The Charles T. Miller Hospital,St. Paul, Minnesota.

Supported by Research Grants HE-5694 and HE-6361 from the National Heart Institute, U. S. PublicHealth Service.

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be distinguished from the specific entity, com-plete transposition.The purpose of this study was to review

the electrocardiographic findings in 54 pa-tients who had complete transposition of thegreat vessels and in whom confirmation of themalformation had been made at necropsy.Our particular purpose evolved into compar-ing results of analysis of the scalar electro-cardiograms with size and type of anatomiccommunication between the two circulations.

Definition of Terms. As used in this report,"complete transposition of the great vessels"designates a condition in which there are twoventricles and two atrioventricular valves;the aorta arises entirely froni the right ven-triele, the pulmonary artery takes origin ex-clusi'vely from the left venitriele, and a ven-tricular septum (with or without a defect)is present. Excluded from this study were allsubjects having a single ventricle, as well asthose showing atresia of an atrioventricularor semilunar valve, even though the great ves-sels were related in. a transposed manner.

Materials and MethodsThe basic mnaterial was a series of 54 infants

with complete transposition of the great vesselsin whom both sealar electrocardiographic studiesand necropsy specimens were available. Each spe-eimen of heart was examined for anatomie detail,the results of which are given in a separate re-port.6 The ages at timne of death ranged between1 week and 2 years: of the 54 patients, 28 wereless than 6 weeks of age, 14 were between 2 and6 months of age, 7 were between 6 and 12 months,and 5 were between 1 and 2 years.Most of the electroeardiograms had been made

with a Sanborn direct-writing multiehannel unit.Readings were made of the 12 conventional leadsand lead V4R. With use of the lead placementsystem of Schmnitt,7 vectoreardiograms also wereobtained in isolated cases. These are presented for

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COMPLETE TRANSPOSITION OF GREAT VESSEL1S

illustrative purposes only, to explain the variousdetails in contour of deflection in the electrocar-diographic tracings. They are not to be interpretedas an extensive study of the vectoreardiogram incomplete transposition of the great vessels.

For each case the electrocardiograms wereanalyzed in two ways. The first consisted of study-ing individual components of the deflections inseveral leads, including a deternlination of thenlean manifest electrical axis and direction of in-scription of the QRS loop. The second consistedin viewing all leads together to determine whetherone or another form of ventricular hypertrophycould be identified.

The criteria employed for signs of right and ofleft ventricular hypertrophy were those proposedby Vince and Keith,8 utilizing Ziegler's9 normalvalues. For identifying biventricular (combinedright and left) hypertrophy, the sources mentionedwere used but with certain modifications, yieldingthe following as criteria of biventricular hyper-trophy:

1. Direct signs of right plus direct signs of leftventricular hypertrophy.

2. Direct signs of right ventricular hypertrophyin association with the following:

a. Q wave 2 mm. or more in lead V6.b. T-wave inversion in V6 after a positive

T in right precordial leads.c. Counterclockwise QRS loop in the frontal

plane.d. Tall biphasic complexes in midprecordial

leads over 50 mm. in height (Katz-Wachtelsign).

3. Direct signs of left ventricular hvpertrophvassociated with the following:

a. R wave 15 mm. or more lead V,.b. Tall biphasic complexes in midprecordial

leads over 50 mm. in height.There were six cases of complete transposition of

the great vessels with special anatomic character-istics such as obstructive malformations of theaortic arch, left ventricular-right atrial communi-cation, and pulmonary stenosis. These were setaside and the electrocardiographic observations onthem will he described in a separate section underresults. Removing these cases from the basic ma-terial left 48 cases among which comparisons couldbe made.

Preliminary StudyDuring the initial phases of this study, the

basic 48 cases were separated into two groups:(1) those with an intact ventricular septum (26cases), and (2) those with a ventricular septaldefect, regardless of size (22 cases). At this phaseof the study, no separation was made on the basisof the status of the ductus arteriosus.


According to earlier reports,3-5 defects in theventricular septum should be suspected in patientswith complete transposition who show any oneor a combination of the following: (1) normalor left axis deviation, (2) an R per cent of RSin lead VI of less than 75 per cent (in thepresence of a loud murmur), (3) an R wave ofless than 10 mm. in lead V4R, (4) adult pro-gression of the QRS complexes in the precordialleads, (5) the Katz-Wachtel phenomenon10-12 inthe midprecordial leads, or (6) certain T-waveconfigurations described by Zuckermann' and Sodi-Pallares.2The aforementioned criteria for the presence

of a ventricular septal defect were not confirmedby our material, as many of these electrocardio-graphic characteristics appeared in both anatomicgroups during the pilot study. It was thus ap-parent that published electrocardiographic criteriafor distinguishing between those cases with anintact ventricular septum and those with a ven-tricular septal defect were not uniformly reliablein our material.

In 47 of the 48 cases studied electrocardiograph-ically (26 with intact ventricular septum and 22with ventricular septal defect), sonme degree ofright ventricular hypertrophy was observed. Thisexisted in the form either of isolated right ven-tricular hypertrophy or within the frameworkof biventricular hypertrophy. For these reasons,the study was directed toward separation of thecases on a different basis.

Earlier studies had not taken into account thestate of the ductus arteriosus. It was decided,therefore, to divide the patients into two groupsaccording to the size, rather than the site, of thecommunication between the svstemic and pulmo-nary arterial circulations.We placed into one group (group I; "small

communication"), those cases with a narrow orobliterated ductus arteriosus and either a smallventricular septal defect (subgroup I A; fivecases) or an intact ventricular septum (subgroupI B; 22 cases). Into the second group (group II;"large communication") were placed those caseshaving either a large ventricular septal defectand closed or narrow patent ductus arteriosus(subgroup II A; 17 cases) or a widely patentductus arteriosus and intact ventricular septum(subgroup II B; four cases). No cases wereobserved in which a widely patent ductus arterio-sus and a large ventricular septal defect coexisted.An interatrial communication was present in eachof the cases studied and took the form either ofa valvular competent patent foramen ovale or a

small atrial septal defect.6 No separation of caseswas made on the basis of the type of interatrialcommunication.

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10ELLIOTT ET AL.

ResultsGroup I-Small Communication (27 Cases)P-I? Interval and P Waves

In one of 27 cases with small communica-tion, a Wolff-Parkinson-White pattern was

observed. In this case, the P-R interval was

shortened owing to the presence of a deltawave preceding the main component of theQRS complex. Among the remaining 26 pa-

tients, the P-R interval was prolonged for age

and rate (0.16 second) in only one instance.The mean P vector in the frontal plane variedbetween +30 and +120 degrees. In most, theP vector approximated +50 degrees. The Pwaves were abnormal in 12 instances. Rightatrial enlargement ("P pulmonale ") was

present in seven patients, and biatrial enlarge-inent was indicated in the other five.QRS Complex (Analysis of Individual Components)

Mean Manifest Electrical Axis. The mean

QRS axis in the frontal plane varied from+70 degrees to +215 degrees (fig. 1). Amongthe 27 patients, the average mean QRS axiswas approximately +135 degrees. Right axisdeviation for age was evident in 13 patients,a normal axis in 14. Vectorial analysis of the

+210 \ 300

A

~~~~~~~00

* = small communication clockwise QRS loop.A = large communication clockwise QR S loop.A = large communication counter clockwise ORS loop.

Figure 1

The mean manifest electrical axis in the frontalplane of 47 patients with small and large communi-cation between the two circulations.

frontal plane showed the QRS loop to be di-rected clockwise in each of the 27 cases (fig. 1).The QRS loop in the horizontal plane (pre-

cordial leads) was oriented anteriorly and tothe right in 23 patients, anteriorly and to theleft in four. Each of the latter four patientsdemonstrated a normal mean QRS axis in thefrontal plane.Lead V, Various configurations of the QRS

complex in lead V, were observed. The threemeajor configurations were: an rR's, an Rs,and a qR pattern (fig. 2). Uncommonly ob-served patterns were, an RS, an R, and anrsR'. The R per cent of RS in lead V1 was75 or more in 23 of the 27 patients (85 percent) and between 50 and 70 per cent in theremaining four.

Midprecordial Leads. The Katz-Wachtelsign (tall diphasic RS complexes at least 50mm. in height in lead V2. V3, or V4) was ob-served in three instances.Lead V6. In lead V6, essentially the fol-

lowing three variations in pattern were ob-served: rS, RS, and qRS. The most commonpattern was that of a small r, and deep S wave(fig. 2). A Q wave, 2 mm. or more, was ob-served in four patients (15 per cent).T Vector

The mean T vector in the frontal planevaried between +25 and +135 degrees. Themajority of patients showed a mean T vectorranging between +30 and +70 degrees. Themean T vector in the horizontal plane (pre-cordial leads) was oriented anteriorly in 15patienits (fig. 2, left) and posteriorly in six.It was perpendicular to the frontal planes infour, and it was indeterminate in two. NotchedT waves in lead V6 were seen in two patients,and positive T waves, higher in the right pre-cordial than in the left precordial leads, wereobserved in six patients.Analysis for Tlypertrophy Patterns

The types of ventricular hypertrophy amongthe 27 patients in group I were observed asfollows:Among four of five patients with a small

ventricular septal defeet and narrow ductusarteriosus (subgroup I A) and 18 of 22 with


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COMPLETE TRANSPOSITION OF GREAT VESSELS

Figure 2Electrocardiog rams and vectorcardiogram showing isolated right ventricular hypertrophyin two infants with complete transposition of the great vessels of the small communi-cation type (intact ventricular septum awd small patent ductus arteriosus). Left. Thehorizontal plane (H) illustrates absence of the "Q loop" as shown by the first fewmilliseconds of the QRS sE loop directed anterior-leftwa,rd. This is reflected by absenceof the Q wave in lead V6. F = frontal plane, S = left sagittal plane. Arrows denotedirection of inscrip,tion. Right. Note the qRi pattern in lead V1.

an intact ventricular septum and narrow orobliterated ductus arteriosus (subgroup II B),isolated right ventricular hypertrophy waspresent (table 1). Combining the results ofthese two subgroups, isolated right ventricularhypertrophy was observed in 22 of 27 instances(81 per cent).In one patient with a small ventricular sep-

tal defect and in three of the four remainingpatients with an intact ventricular septum,

TableIncidence of Ventricular Hypertrophy andp,osition (48 Cases)

Group I-Small communication(27 cases)

signs of biventricular hypertrophy werepresent.

In the one remaining patient with an intactventricular septum, the presence of the Wolff-Parkinson-White pattern precluded evalua-tion of hypertrophy.Group II-Large Communication (21 Cases)P-R Interval and P Wave

Among the 21 patients with a large com-munication, the P-R interval was prolonged

1Atrial Enlargement in Complete Trans-

Group II-Large communication(21 cases)

Group I A: Group I B: intact sep- Group II A: Group Il B: intact sep-Small VSD (5) tum; small PDA (22*) large VSD (17) tum; large PDA (4)

P waves BVH RVH BVH RVH BVH RVH BVH RVH

Normal 1 1 2 10 3 1 3 0RAE 0 2 0 5 2 1 0 0

LAE 0 0 0 0 4 0 0 0BAE 0 1 1 3 4 2 1 0

Totals 1 4 3 18 13 4 4 0

*One case with Wolff-Parkinson-White syndrome precluded evaluation of hypertrophy.VSD, ventricular septal defect; PDA, patent ductus arteriosus; BVH, biventricular hyper-

trophy; RVH, right ventricular hypertrophy; RAE, LAE, and BAE, right, left, and biatrialenlargement, respectively.


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ELLIOTT ET AL.

for age and rate (0.18 second) in two. Themean P vector in the frontal plane varied be-tween +90 and +45 degrees, the average being+60 degrees. Atrial enlargement was observedin 14 of the 21 patients. Left atrial enlarge-ment was observed in four patients, biatrialenlargement in seven, and right atrial enlarge-ment in three (table 1.).QRS Complex (Analysis of Individual Components)

Mean Manifest Electrical Axis. In the 21cases, the mean QRS axis in the frontal planevaried between -15 and +190 degrees, theaverage being approximately +120 degrees(fig. 1). Right axis deviation for age was evi-dent in eight instanees and a niormal axis in12; left axis deviation was observed in one.Among these 21 patients, the QRS loop wasinscribed in a clockwise direction in 16 andcounterclockwise in five (fig. 1).The QRS loop in the horizontal plane (pre-

cordial leads) was oriented anteriorly and tothe right in 13 patients, anteriorly and to theleft in five, and to the left, equally anteriorand posterior, in three.Lead V1. The QRS complex in lead VI

showed varying configurations. The patternswere of the R, rsR', rR', and RS types. Thepercentage of R of RS in lead V1 was 75 ormore in 15 patients (71 per cent). In the re-maining six patients the percentage of Rvaried between 43 and 72 (fig. 3, tpper left).

Midprecordial Leads. Tall diphasic RS com-plexes over 50 mm. in amplitude in the mid-precordial leads were observed in 10 patients(48 per cent; fig. 4, right).Lead V6. Essentially three patterns were

observed in lead V6. These included qRS, RS,and rS patterns. Among the 18 patients inwhom a Q wave appeared in lead V6 (85 percent) the amplitude varied in depth from 1 to6 mm. (figs. 3 and 4). Among 16 of these 18patients, the Q wave was 2 mm. or more.T VectorThe inean T vector in the frontal plane var-

ied between zero and +160 degrees. In thevast majority of patients it ranged between+45 and +60 degrees. In the horizontal planeit was oriented anteriorly in 13 instances (fig.3, lower left), posteriorly in five, and perpen-

dicular to the frontal plane in three (fig. 3,upper right). Positive T waves, higher in theright precordial leads than in the left, wereobserved in three patients.Analysis for Hypertrophy Petterns

In considering the type of hypertrophy pat-terns among the 21 patients conmprising groupII (large communication), the following wereobserved.Among 13 of 17 patients with a large ven-

tricular septal defect, and in each of the fourpatients with a large patent ductus arteriosusand intact ventricular septum, evidence of bi-ventricular hypertrophy was observed (table1). Thus, among 21 patients with large eom-munication, biventricular hypertrophy wasobserved in 17 instanees (80 per cent). In theremaining four patients with large ventricu-lar septal defects, isolated right ventrieularhypertrophy was observed.Comparisons of Electrocardiographic Findings

In the two anatomic groups, the most re-liable indication for the preseniee of a smallcommunieation was signs of isolated rightventricular hypertrophy, which were found in22 of 27 (81 per cent) cases in group I (table1); whereas, most indicative for large com-munication were eleetrocardiographic signs ofbiventricular hypertrophy. which appeared in17 of 21 (80 per cent) cases in group II (ta-ble 1).

It is significanit that none of the 48 patientsconmprising groups I and II exhibited signsof isolated left ventricular hypertrophy. Fur-thermore, among the patients with bivemitric-ular hypertrophy, signs of right ventricularhypertrophy predonminated over signs of leftventricular hypertrophly in the vast majorityof cases.When it came to analyzingfc the differences

among the individual components of the QRScomplex, important distinctions were absentexcept, perhaps, for the following:

1. The direction of inscription employed bythe QRS loop in the frontal plane: Anongpatients of groups I and II in whom the meanmanifest electrical axis was normal, the QRSloop was inscribed counterclockwise only incases with large communication (fig. 1).


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Figure 3Electrocardiograms and vectorcardiograms showing biventricular hypertrophy in threepatients of the large communication type. In each, the initial cardiac vector ("Q loop")in the (H) plane is accentuated, producing relatively deep Q waves in left precordialleads. Abbreviations as in figure 2. Upper left. Large ventricular septal defect. Uncom-mon variety of biventricular hypertrophy. There is relatively more left ventricularpredominance than is usually observed in patients with complete transposition. Upperright. Common variety of biventricular hypertrophy. Prevailing pattern is right ventricu-lar hypertrophy [wide-open anterior-rightward clockwise QRS loop (H) plaine pro-ducing extremely tall fR waves in lead Vl]. In contradistinction to tracings in figure2, the "Q loop" is accentuated. Lower left and lower right. Tracings at 2 and S weeksrespectively in patient with intact ventricular septum and large p,atent ductus arteriosus.In each, the prevailing pattern is right ventricular hypertrophy. Characteristically, the"Q loop" is accentuated. Note the classic figure-of-eight pattern of right ventricularhypertrophy (H plane) in lower right. N/2 = one-half standardization.

2. Q wave in lead V>,: Only in patients witha small communication was a Q wave observedin lead V1. Furthermore, this sign among

patients in this study is in itself significant,


since other investigators4' 5, 13 rarely, if ever,observed this pattern in complete transposi-tion.

3. Q wave in the left precordial leads: A Q

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Figure 4Electrocardiograms showing biventricular hypertrophy in 2 patients with completetransposition of the great vessels with large ventricular septal defects. Left and right.Each tracing shows evidence of right ventricular hypertrophy. Left ventriculaT hyper-trophy additionally is indicated in each by an accentuated "Q loop" directed anterior-rightward, represented by a deep Q wave in lead V6. Note the Katz-WVachtel sign inlead V2 of the tracina on the right. N/2 - one-half normal standardization.

wave in lead V6 was observed in only 15 percent with small communication while 85 percent with large communication exhibited thissign. This latter finding is significant, forWatson and Keith'4 observed Q waves in leadV6 in only 13 per cent of their patients with"transposition of the great vessels."

Cases with Unusual Associated Anomalies

In addition to the foregoing 48 subjects,there were six cases with unusual associatedanomalies. These will now be considered.

Obstructive malformiations of the aorticarch (two cases): In two patients with anintact ventricular septum, a preduetal coare-tation was observed in one, and tubularhypoplasia of the aortic arch in another. Elec-trocardiographically, each showed evidence ofmild degrees of left axis deviation for age(+15 degrees and -30 degrees), a counter-clockwise QRS loop in the frontal plane, andcoexisting left atrial enlargement. Left ven-

tricular hypertrophy was observed in the pa-tient with tubular hypoplasia of the aorticarch (fig. 5, upper), and biventricular hyper-trophy (with predominant left ventricularhypertrophy) in the patient with coaretationof the aorta.

Left ventricular-right atrial commanication(two cases): The typical electrocardiogram ofpatients with ventricular septal defects ofthe persistent common atrioventricular canaltype'5 was observed in two cases with a leftventricular-right atrial communication, name-ly, marked left axis deviation (-120 degreesand -90 degrees), a counterclockwise QRSloop in the frontal plane, and right or biven-tricular hypertrophy (fig. 5, lower left andlower right).Pulmonary valvular stentosis (two cases):

In each of the two patients with a large ven-tricular septal defect and pulmonary valvularstenosis, isolated right ventricular hyper-trophy was observed.


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Figure 5Upper. Electrocardiogram in a 1-month-old infant with complete transposition andcoarctation of the aorta. There is mild left axis deviation for age. The precordial leadsshow relatively deep S waves in leads V4R and Vl, indicating left ventricular) hyper-trophy. Lower left and lower right. Electrocardiograms in two patients with completetranspositionS and left ventricular-right atrial communication. Each shows featuresusually observed in patients with isolated ventricular septal defects of the "A-Vcommune"2 type.


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Discussion.For various reasons, in patients with com-

plete transposition of the great vessels, it isdesirable to know the state of the ventricularseptum.

Earlier reports have suggested that thepresence of right axis deviation was a sign,among others, of an intact ventricular sep-tum, whereas the presence of normal or of leftaxis deviation favored the existence of a ven-tricular septal defect. Our preliminary studydid not establish such an association.

It seemed important, then, to work from afunctional, rather than from a primary ana-tomic point of view, and to consider the in-fluence of absence or presence of flow throughthe ductus arteriosus, as well as through thevenitricular septum.We divided our cases into two groups on

this basis. Group I was composed of patientswith "small communication," that is, showingeither a narrow or obliterated ductus arteri-osus and an intact ventricular septum or asmall ventricular septal defect. Group II wasformed by patients with large communication,that is, showing either a wide patent ductusarteriosus with an intact ventricular septumor a LArge ventricular septal defect. The es-sential difference between the two groupsrevolved about the type of hvpertrophy exhib-ited.

In 47 of the 48 patients without unusualassociated anomalies, signs of right ventricu-lar hypertrophy were present. However, someshowed only this sign while others showedsigns of left ventricular hypertrophy, as well("biventricular hypertrophy").In group I (small coinmunieation) the elec-

trocardiogram showed isolated right ventric-ular hypertrophy in 81 per cent of the cases.In group II (large communication) the elec-trocardiogram showed biventricular hyper-trophy in 8Q per cent of the cases.

These results indicate a strong (althoughnot absolute) basis for distinguishing betweencases with a snmall or large communicationbetween the ventricles or great arteries.When a large conununicatioin is present, the

0lectrocardiogranm cannot distiiguish between

a large ventricular septal defect and a widepatent ductus arteriosus associated with anintact ventricular septum.To reeognize signs of additional left ven-

tricular hypertrophy in the presence of pre-dominant right ventricular hypertrophy incomplete transposition, one is dependent to alarge extent upon the direction and magnitudeof the initial vector forces of the QRS initer-val, as viewed in the horizontal plane. Thisfeature, to our knowledge, has not been em-phasized for complete transposition.

Cabrera and Gaxiola,l6 among others, citedevidence itLat the initial forces of the QRSinterval in the horizontal plane (termed bvthem a "Q loop"') are signs primarily of de-polarization of the ventricular septum. Theseinitial cardiae vectors show increased magmi-tude when there is left or biventricular "over-load." In contrast, the "Q loop" shows de-creased magnitude when there is isolated rightventricular "overload." In the left precordialleads, increased magnitude of the "Q loop':is represented by significant Q waves (2 mm.or more), whereas decreased magnitude of the"Q loop" is represented simply as either anabsent or sinall Q wave (2 mm. or less).

These views were confirmed by the presenceof a Q wave, 2 mm. or more, in 16 of the 21patients with large communication, and werefurther confirmed wherein we recorded bothscalar electrocardiograms and vectoreardio-grams (fig. 2, left, and fig. 3).

In addition to the foregoing 48 patients,two showed obstructive malformations of theaortic arch, and two exhibited a left ventrie-ular-right atrial communication. Left axis de-viation was observed in each of these, whereasthis electrical phenomenon was observed inonly one patient with an uncomplicated largecomimunication and in none of the patientswith a small communication. Left axis devia-tion aniong patients with transposed greatvessels usually suggests tricuspid atresia orcommon ventriele.17 Our observations, how-ever, indicate that left ventricular-right atrialcommulnieatiomi or obstructive malformationsof the aortic arch should be considered if leftaxis deviationi, assoeiated with predominaiit


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signs of left ventricular hypertrophy, is ob-served in patients with complete transpositionof the great vessels.

SummaryA correlative study of necropsy findings

and electrocardiography in 54 cases of com-plete transposition of the great vessels wasmade to determine whether or not specificelectrical patterns could predict the status ofthe ventricular septum. It became apparentthat published criteria for distinguishing be-tween patients with a ventricular septal defectand those with an intact ventricular septumwere not uniformly reliable.

Rather than the location of a communica-tion, the important factor in differentiationdepended upon the size of the opening, be itbetween the ventricles or through a patentductus arteriosus.

Cases were divided into two groups: Ingroup I were those with a small communica-tion, and in group II were those with a largecommunication between the greater and lessercirculations. The group with small communi-cation showed a narrow or obliterated ductusarteriosus and an intaet ventricular septum,or a small ventricular septal defect. In groupII there was either a wide patent ductus arte-riosus with an intact ventricular septum or alarge ventricular septal defect.

In group I the electrocardiogram predomi-nantly showed isolated right ventricular hy-pertrophy, whereas, in group II, biventricularhypertrophy was the usual finding.Among the five patients in whom the mean

manifest electrical axis was deviated to theleft, two showed obstructive malformations ofthe aortic arch, and two left ventricular-rightatrial communication. The fifth case was sim-ply one of a large communication withoutcomplicating anomalies.

References1. ZUCKERMANN, R., OISNEROS, F., AND NOVELO, S.:

El electrocardiograma en algunas cardiopatiascongenitas. Arch Inst. cardiol. Mexieo 21: 61,1951.

2. SODI-PALLARES, D., PORTILLO, B., CISNEROS, F.,DE LA CRUZ, M. V., AND AcoSTA, A. R.: Electro-cardiography in infants and children. Pediat.Clin. North America 5: 871, 1958.


3. ANDERSON, R. C., AND ADAkS, P., JR.: Differenti-ation of associated cardiac defects in transpo-sition of the great vessels. Journal Lancet 75:60, 1955.

4. KEITH, J. D., ROWE, R. D., AND VLAD, P.: HeartDisease in Infancy and Childhood. New York,Macmillan Company, 1958, p. 492.

5. NOONAN, J. A., NADAS, A. S., RUDOLPH, A. M.,AND HARRIS, G. B. C.: Transposition of thegreat arteries (continued) : A correlation ofclinical physiologic and autopsy data. NewEngland J. Med. 263: 637, 1960.

6. ELLIOTT, L. P., NEUFELD, H. N., ANDERSON,R. C., ADAMS, P., JR., AND EDWARDS, J. E.:Complete transposition of the great vessels. I.An anatomic study of sixty cases. Circulation27: 1105, 1963.

7. SCHMITT, O. H., AND SIMONSON, E.: Symposiumon electrocardiography and vectoreardiography.The present status of vectoreardiography. Arch.Int. Med. 96: 574, 1955.

8. VINCE, D. J., AND KEITH, J. D.: The electro-cardiogram in ventricular septal defect. Circu-lation 23: 225, 1961.

9. ZIEGLER, R. F.: Electrocardiographic Studies inNormal Infants and Children. Springfield,Illinois, Charles C Thomas, 1951.

10. KATZ, L. N., AND WACHTEL, H.: The diphasicQRS type of electrocardiogram in congenitalheart disease. Am. Heart J. 13: 202, 1937.

11. SODI-PALLARES, D., AND CALDER, R. M.: NewBases of Electrocardiography. St. Louis, C. V.Mosby Company, 1956, p. 255.

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13. LUNA, R. L., AND CROW, E. W.: Correlation ofdegree of pulmonary hypertension with mor-phology of the QRS in lead V1 in cases withevidence of systolic overloading of the rightventricle. Am. Heart J. 62: 481, 1961.

14. WATSON, D. G., AND KEITH, J. D.: The Q wavein lead V6 in heart disease of infancy andchildhood, with special reference to diastolicloading. Am. Heart J. 63: 629, 1962.

15. NEUFELD, H. N., TITUS, J. L., DUSHANE,J. W., BURCHELL, H. B., AND EDWARDS, J. E.:Isolated ventricular septal defect of the per-sistent common atrioventricular canal type.Circulation 23: 685, 1961.

16. CABRERA, E., AND GAXIOLA, A.: Diagnostic con-tribution of the vectorcardiogram in hemo-dynamic overloading of the heart. Am. HeartJ. 60: 296, 1960.

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HENRY N. NEUFELDLARRY P. ELLIOTT, RAY C. ANDERSON, NAIP TUNA, PAUL ADAMS, JR. and

AnalysisComplete Transposition of the Great Vessels: II. An Electrocardiographic

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