Clinical Review & Education
Challenges in Clinical Electrocardiography
Electrocardiographic Findings in a Woman With Dextrocardia
and Cyanosis
Yingjie Zhang, MD; Hexi Jiang, MD; Renguang Liu, MD
A 31-year-old woman with a history of progressive cyanosis and
dyspnea since childhood developed chest tightness and shortness
of breath in the 20 days after a cold and was admitted to the hos-
pital. On admission, her blood pressure was 108/70 mm Hg, her heart
rate was 84 beats per minute, and her respiratory rate was 22 breaths
per minute. Physical examination revealed lip cyanosis; the apex
beat was located at 0.5 cm outside of the right clavicle line; and a
systolic ejection murmur was detected at the third and fourth
intercostal at the right side of the sternum. The B-type natriuretic
peptide level was substantially increased. The 12-lead electrocar-
diogram (ECG) (Figure 1) showed negative P wave in leads aVL and
I but positive P wave in lead aVR. QRS complexes presented as rS
complex in lead V1 and QR in V2 to V6. The amplitude of R wave
decreased progressively from lead V2 to V6.
Question: How should the ECG be analyzed and how to
further diagnose?
Interpretation
After limb leads misconnection was excluded, 2 possible reasons
were considered for the abnormal right-axis deviation of the P wave.
One was mirror-image dextrocardia, in which the patient’s ectopic
heart is reversely located in the right thorax. However, the QR com-
plex in leads V2 to V6 did not support the diagnosis of mirror-image
dextrocardia. The second possible diagnosis was dextroversion with
left atrial rhythm, considering the patient’s congenital cyanosis.
The echocardiogram suggested tetralogy of Fallot and mirror-
image dextrocardia. The tetralogy of Fallot was revealed as pulmo-
nary stenosis and right ventricular outflow tract obstruction, over-
riding aorta over the ventricular septal defect, the ventricular septal
defect of 22 mm in diameter, and the right ventricular hypertrophy.
The bidirectional flow through the ventricular septal defect with a
left-to-right dominance was detected. Moreover, mirror imaging
Figure 1. Initial Electrocardiogram
I aVR
II aVL
III aVF
Standard 12-lead electrocardiogram on admission.
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of the normal visceral and atrium was present; the cardiac apex was
pointing to the right; and the aortic arch descending reversed to the
right thorax.
The ECG leads were relocated to change the mirror imaging
into a normal one (Figure 2). For this correction, the left arm lead
was placed on the right arm; the right arm lead was placed on the
left arm; and the precordial leads were placed across the right
rather than the left precordium (with the V1-V6 leads placed in the
V2, V1, and V3R-V6R positions). On the corrected ECG, sinus rhythm
was indicated by the positive P wave in leads I, II, and aVL, and the
negative P wave in lead aVR; right ventricular hypertrophy was
suggested by the QRS axis deviated to the right (+120°), qR com-
plex in lead V1, and the voltage of the S wave in lead V5 over 0.5
mV. The patient refused surgery and was discharged when her
symptoms were relieved.
Discussion
In general, the heart shift to the right thorax is referred to as dex-
trocardia, including mirror-image dextrocardia, heart dextrover-
sion, and heart dextroposition.1,2 Mirror-image dextrocardia is
characterized by mirror-image change of the normal heart gener-
ally accompanied by situs inversus viscerum, but only 3% to 10%
of patients have intracardiac anomaly.3,4 The ECG is characterized
by negative P wave in leads I and aVL, and positive P wave in lead
aVR; the QRS complexes in leads V1 through V6 indicate the activa-
tion of the ventricle in the right thorax.5 Cardiac dextroversion
refers to the heart rotation into the right thorax with its normal
chambers and adjacency relations, although the axis of the heart
still points to the left. No situs inversus viscerum exists, but the
intracardiac anomaly is commonly seen. The ECG reveals positive
P wave in lead I and QRS complexes in leads V1 through V6, indicat-
ing the activation of the ventricle in the right thorax. 6 Heart
V1 V4
V2 V5
V3 V6
(Reprinted) JAMA Internal Medicine Published online June 25, 2018 E1
 Clinical Review & Education Challenges in Clinical Electrocardiography

Figure 2. Electrocardiogram After Correction

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

The 12-lead electrocardiogram recorded based on the correction method of the mirror-image dextrocardia.

dextroposition presents under the situation of severe extracardiac
abnormalities, such as lung, pleural, or diaphragmatic disease;
these pathological changes push the heart rightward, even into
the right thorax, but the heart structure is normal. 2 The ECG
reveals normal QRS complex in precordial leads, and the QRS volt-
age progressively decreases from lead V4 to V6.
The characteristics of P wave and QRS complex are helpful to
make a differentiation diagnosis between the 3 types of dextro-
cardia. Situs inversus viscerum and congenital cyanosis are help-
ful for the primary diagnosis of congenital heart disease. Finally,
echocardiography is reliable for the definite diagnosis. A
corrected 12-lead ECG is helpful to recognize mirror-image
dextrocardia in the situation without single ventricle anomaly.3
In this patient, the negative P wave in lead I suggested mirror-
image dextrocardia, but QRS complex in lead V1 did not support
this conclusion. Given the congenital cyanosis, dextroversion
with left atrial rhythm was reasonably suspected. Finally, mirror-
image dextrocardia with tetralogy of Fallot was verified by
echocardiography.
Take-Home Points
• There are 3 conditions classified as dextrocardia: mirror-image
dextrocardia, dextroversion, and dextroposition. In them, the
anatomic and clinical conditions and ECG manifestations are
different from one another.
• The characteristics of abnormal P wave in lead I and QRS
complex in precordial leads are helpful to detect mirror-image
dextrocardia.
• Situs inversus viscerum and congenital cyanosis are helpful to
find the underlying congenital heart disease.
• Echocardiography is reliable for the definite diagnosis.

ARTICLE INFORMATION
Author Affiliations: Cardiovascular Department of
the First Affiliated Hospital of Jinzhou Medical
University, Jinzhou, Liaoning Province, China
(Zhang, Jiang); Cardiovascular Institute of the First
Affiliated Hospital of Jinzhou Medical University,
Jinzhou, Liaoning Province, China (Liu).
Corresponding Author: Renguang Liu, MD,
Cardiovascular Institute of the First Affiliated
Hospital of Jinzhou Medical University, Renmin
Street, Jinzhou, Liaoning Province, China
(liurenguanglaoshi@126.com).
Section Editors: Zachary D. Goldberger, MD, MS;
Nora Goldschlager, MD; Elsayed Z. Soliman, MD,
MSc, MS.
Published Online: June 25, 2018.
doi:10.1001/jamainternmed.2018.2682
Conflict of Interest Disclosures: None reported. diagnoses? Circulation. 2016;134(7):567-569.
Additional Contributions: We thank the patient for doi:10.1161/CIRCULATIONAHA.116.024356
granting permission to publish this information. 5. Bharati S, Lev M. Positional variations of the
heart and its component chambers. Circulation.
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