Diagnosis of ventricular aneurysm and other severe segmental left ventricular dysfunction consequent to a myocardial infarction in the presence of right bundle branch block: ECG correlates of a positive diagnosis made via echocardiography and/or contrast ventriculography

Background: A diagnostic ECG sign of a ventricular aneurysm (VA) consequent to a myocardial infarction (MI) in the presence of complete left bundle branch block was recently described, and consists of the presence of ST-segment elevation (+ST), instead of the expected ST-segment depression (-ST), in leads V_4-6. Generally, complete right bundle branch block (RBBB) is associated with -ST in ECC leads V_1-3. We hypothesized that stable +ST, instead of the expected -ST in leads V_1-3 in patients with RBBB could be also diagnostic of a VA and other severe segmental left ventricular dysfunction (VA/SSD). Thus, this study was performed to explore the feasibility of using the ECG to diagnose a VA/SSD in the presence of RBBB, and to evaluate the determinants of such diagnosis. Methods: The frequency of +ST ≥1 mm in leads V_1-3 was assessed in patients with RBBB, prior MI, and a VA/SSD diagnosed by echocardiography and/or contrast left cine-ventriculography. The ECC correlates for a positive or negative diagnosis of a VA/SSD were explored. Results: Out of 4197 files of our cohort of the Cardiology Clinic, RBBB was detected in 175 patients. Of these, 28 had an old MI, and had a VA/SSD diagnosed by ≥1 of noninvasive and/or invasive non-ECG tests. Twenty-one of these 28 patients had stable +ST in ≥1 of leads V_1-3 (Group 1), and 7 did not (Group 2). Thus, the sensitivity of this ECG criterion for the diagnosis of VA/SSD was 75%, and the specificity was 100% in this highly selective group. VA/SSD in the septal and anterior myocardial regions was more frequent in the patients of Group 1, than in the patients of Group 2 (P = 0.03 and 0.02, correspondingly). The number of myocardial territories involved with the VA/SSD, or the ejection fraction were not different in the two groups (P = 0.65 and 0.55, correspondingly). Conclusion: VA/SSD can be diagnosed in the presence of RBBB by the concordant to the QRS repolarization changes (+ST) in leads V _1-3. Positivity of this ECG marker for VA/SSD correlates with involvement of the septal or anterior myocardial regions, and represents mechanistically a superimposition of primary repolarization alterations, overcoming the secondary such changes.