Arthur Grishman

Spatial vectorcardiography: Technique for the simultaneous recording of the frontal, sagittal, and horizontal projections. I

Abstract A technique for the simultaneous recording of a frontal, sagittal, and horizontal vectorcardiogram is described. The geometric arrangement selected for electrode placement is that of a cube. The reasons for preferring the cube arrangement to the equilateral tetrahedron are discussed.

A study of the electrocardiogram and vectorcardiogram in congenital heart disease

Abstract 1.1. The electrocardiograms and spatial vectorcardiograms of 135 patients with congenital heart disease, in whom the diagnosis was well established, were analyzed. Our findings were compared with those of other authors. 2.2. No pathognomonic electrocardiographic or vectorcardiographic pattern is associated with any particular anatomic lesion. 3.3. Both the electrocardiogram and the vectorcardiogram, but particularly the latter, are of considerable aid in the differential diagnosis of the various malformations by indicating the dominant type of ventricular hypertrophy present. 4.4. In general, patients with the tetralogy of Fallot, pulmonic stenosis, interatrial septal defect, and Eisenmengers complex show right ventricular hypertrophy; those with tricuspid atresia, subaortic or aortic stenosis, and coarctation of the aorta show left ventricular hypertrophy, while those with uncomplicated patent ductus arteriosus, interventricular septal defect, and idiopathic dilatation of the pulmonary artery show a normal balance of electrical forces. 5.5. The determination of electrical axis from the standard electrocardiographic leads is found to be of little value in determining the type of ventricular hypertrophy present.

The relation of pectus excavatum to heart disease

Abstract 1.1. Pectus excavatum is a congenital thoracic deformity which, in moderate and severe cases, may result in profound disturbances of cardiorespiratory physiology. 2.2. The radiographs of the chest in this condition indicate cardiac displacement, impingement, and rotation. 3.3. The electrocardiographic and vectorcardiographic findings are the result of cardiac rotation and do not reveal any evidence of intraventricular conduction defect or myocardial damage. The rSr′ or rSR′ pattern observed in V 1 is a variation of normal and does not indicate incomplete right bundle branch block. 4.4. Cardiac catheterization in one of the symptomatic adults was of great interest in that a normal cardiac output was observed at rest. After ten minutes of standard exercise, a definite fall in cardiac output was recorded, with only a minimal rise in pulmonary artery pressure. 5.5. The mechanisms responsible for cardiac disability in this condition are thought to result from 5.1.a. a decreased return of blood to the right heart, 5.2.b. cardiac arrhythmias secondary to atrial impingement, 5.3.c. restriction of expansion of the heart, and 5.4.d. a decrease in respiratory reserve. 6.6. This deformity can be corrected satisfactorily by operation with good physiologic and cosmetic results.

A study of the electrocardiogram and vectorcardiogram in congenital heart disease. III. Electrocardiographic and vectorcardiographic findings in various malformations.

Abstract 1. 1. The electrocardiograms and spatial vectorcardiograms of 135 patients with congenital heart disease, in whom the diagnosis was well established, were analyzed. Our findings were compared with those of other authors. 2. 2. No pathognomonic electrocardiographic or vectorcardiographic pattern is associated with any particular anatomic lesion. 3. 3. Both the electrocardiogram and the vectorcardiogram, but particularly the latter, are of considerable aid in the differential diagnosis of the various malformations by indicating the dominant type of ventricular hypertrophy present. 4. 4. In general, patients with the tetralogy of Fallot, pulmonic stenosis, interatrial septal defect, and Eisenmengers complex show right ventricular hypertrophy; those with tricuspid atresia, subaortic or aortic stenosis, and coarctation of the aorta show left ventricular hypertrophy, while those with uncomplicated patent ductus arteriosus, interventricular septal defect, and idiopathic dilatation of the pulmonary artery show a normal balance of electrical forces. 5. 5. The determination of electrical axis from the standard electrocardiographic leads is found to be of little value in determining the type of ventricular hypertrophy present.

Spatial vectorcardiography: The normal vectorcardiogram. VI

Abstract 1. 1. Vectorcardiograms have been recorded and photographed simultaneously in the horizontal, sagittal, and frontal planes in sixty-two normal children and adults. 2. 2. The horizontal plane QRS loop in normal adults is characterized by an initial deflection anteriorly to the right and is then inscribed in a counterclockwise direction to the left and posteriorly. 3. 3. The sagittal plane QRS loop in normal adults is characterized by an initial deflection anteriorly, usually superiorly, and is then inscribed in a clockwise direction inferiorly and posteriorly. 4. 4. The frontal plane QRS loop may be inscribed in a clockwise or counter-clockwise direction depending upon the axis of the QRS loop. 5. 5. The vectorcardiograms of children are usually oriented more anteriorly, inferiorly, and to the right than those of adults. 6. 6. Multiple thoracic unipolar leads can be derived from the horizontal plane QRS loop, esophageal leads from the sagittal, and standard extremity and unipolar leads from the frontal. 7. 7. The alterations of the QRS and T loops with respiration are described. 8. 8. The clinical advantages and theoretical implications of spatial vectorcardiography are discussed.

Spatial vectorcardiography: Myocardial infarction. V.

Abstract 1. 1. Simultaneously recorded frontal, sagittal, and horizontal plane vectorcardiograms are described in sixty-seven persons with myocardial infarction. 2. 2. The orientation of the QRS sE loops after infarction depended upon the localization of the infarcted area. 3. 3. The vector loops in infarction are correlated with standard, unipolar extremity, multiple unipolar thoracic, and esophageal leads. 4. 4. Spatial vectorcardiography as recorded by the technique employed in the present study is a superior method for the analysis of the spatial distribution of electromotive forces in infarction.

Wolff-Parkinson-White syndrome: A vectorcardiographic, electrocardiographic and clinical study

Abstract 1. 1. Thirty-eight cases of Wolff-Parkinson-White syndrome are analyzed by vectorcardiographic and electrocardiographic correlative study. 2. 2. Although electrocardiographic grouping into types A and B has been challenged as being unnecessary, vectorially the delta vector or QRS sE loops in the horizontal plane fell into two distinct quadrants which we have designated as groups A and B, respectively. In group A the delta vector is anteriorly oriented, and in the +30 degrees and +120 degrees quadrant in the horizontal plane. In group B the delta vector is oriented to the left, and in the −60 degrees to +30 degrees quadrant in the horizontal plane. In group A the QRS sE loop was more commonly inferiorly oriented, whereas in group B the QRS sE loop was more commonly superiorly oriented, although there was overlap. 3. 3. The delta portion of the QRS sE loop was usually oriented in the same direction as the remainder of the QRS sE loop, and determined the spatial orientation of the QRS sE loop. 4. 4. Some of the clinical features of this syndrome are briefly discussed, including the association with paroxysmal tachycardia and atrial fibrillation or flutter. 5. 5. The pitfalls in the diagnosis of myocardial infarction in the presence of this syndrome are stressed. 6. 6. In patients whose conduction became normal the QRS sE loops that were observed were usually greatly dissimilar from those recorded during WPW conduction. This observation, in conjunction with the electro-kymographic and catheterization studies of others which demonstrated no abnormal asynchronysm of ventricular contraction, suggests to us that early excitation of just one ventricle cannot take place, and that therefore not only the initial portion of spread of excitation is anomalous, but also the entire conduction through both ventricles may be anomalous.

Right Bundle-Branch Block. Hemodynamic, Vectorcardiographic and Electrocardiographic Observations

The time intervals between the onset of ventricular depolarization and of right ventricular contraction were studied in 36 patients, by means of cardiac catheterization, and were correlated with their vectorcardiograms and electrocardiograms. The onset of right ventricular contraction was delayed in six subjects without heart disease but with the electrocardiographic picture of right bundle-branch block. The onset of right ventricular contraction was found to be normal in 10 of 15 patients with right ventricular hypertrophy with the electrocardiographic picture of right bundle branch block. This indicates that this electrocardiographic configuration is not necessarily accompanied by delayed right ventricular contraction.

Spatial vectorcardiography: Left bundle branch block and left ventricular hypertrophy. II

Abstract 1.1. Simultaneously recorded frontal, sagittal, and horizontal plane vectorcardiograms are described in twenty patients with left ventricular hyerptrophy, fourteen patients with left bundle branch block, and two patients with intermittent left bundle branch block. 2.2. In left ventricular hypertrophy, the QRS sE loops in the frontal plane were usually inscribed in a counterclockwise direction in the I and VI sextants; in the sagittal plane, in a clockwise direction and posteriorly; in the horizontal plane, in a counterclockwise direction posteriorly and to the left. 3.3. In left bundle branch block, the QRS sE loops in the frontal plane were inscribed in the I and VI sextants in a counterclockwise direction; in the sagittal plane, in a clockwise direction posteriorly and upward; in the horizontal plane, in a clockwise direction posteriorly and to the left. 4.4. There was no delay in the inscription of the QRS sE loop in left ventricular hypertrophy while there was definite delay in left bundle branch block. 5.5. The significance of these findings is discussed.

The vectorcardiogram and electrocardiogram in interatrial septal defect; analysis of 30 cases.

Abstract 1. 1. Thirty consecutive, well-authenticated cases of interatrial septal defect have been studied vectorcardiographically and electrocardiographically. 2. 2. An rSR′ configuration was present in eighteen of the thirty cases. 3. 3. The electrocardiogram, applying the criteria described, detected the Presence of right ventricular preponderance in thirteen of the thirty patients. 4. 4. The vectorcardiogram demonstrated right ventricular preponderance in twenty-nine of thirty cases. 5. 5. Four types of spatial QRS loops characteristic of right ventricular preponderance are described, including Type 4 with terminal conduction delay. 6. 6. There is no consistent relationship in this study between right ventricular pressures and electrocardiographic or vectorcardiographic patterns, though rSR′ configurations were found to have a lower average systolic pressure than the non-rSR′ group. 7. 7. The theories of the pathophysiologic significance of the rSR′ are reviewed. Most investigators believe that the tall R in V1 reflects higher ventricular pressures than does the rSR′, but there are many exceptions to this observation. 8. 8. Axis deviation does not appear to be a reliable index of the degree of right ventricular hypertrophy, nor does it vary consistently with changing ventricular systolic pressures.