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Challenges in Clinical Electrocardiography
December 10, 2018

Bundle Branch Block Site in a Patient With a Right-Lying Heart and Wide QRS Complex

Author Affiliations
  • 1The Cardiovascular Institute of the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning Province, China
  • 2Bridgeport Hospital, Yale New Haven Health System, Bridgeport, Connecticut
JAMA Intern Med. Published online December 10, 2018. doi:10.1001/jamainternmed.2018.6709

A woman in her 30s was first noted to have the apex beat located on the right side of her chest at 2 years of age by her mother. She was referred for a cardiac evaluation after an electrocardiogram (ECG) performed on a routine health evaluation showed a wide QRS complex. The patient did not have chest wall deformity. The maximal cardiac impulse was noted to be in the right seventh interspace. A pathological diastolic murmur was detected at apex and the third and fourth intercostals at the right side of the sternum. Her initial ECG (Figure 1) showed that the P wave was positive in leads I and II, and negative in lead aVR (after limb lead misplacement was excluded). The PR interval was 140 milliseconds, and the QRS duration was prolonged (140 milliseconds) with slurred R waves in leads V1 through V6.

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