We reviewed the insightful figure by Li et al with great interest and thank them for their comments on our article.
1
Indeed, the electrocardiographic (ECG) changes showcased in their figure are suggestive of limb lead reversal. However, in order to conclude that these changes are inconsistent with corrected dextrocardia, ECG changes associated with corrected dextrocardia would be required as a comparator. Unfortunately, there are no case studies in the literature of these ECG changes for reference, simply because dextrocardia is not routinely reversed. Hokamaki et al.2
also described a case of hiatal hernia with cardiac compression with no such changes, but their case involved a hiatal hernia that was located posteriorly in the thoracic cavity that did not rotate the heart. As such, no change in limb lead axis was noted after the hernia repair in their dynamic ECG assessments.Ideally, procurement of another preoperative ECG on our patient prior to her hernia repair would resolve this issue. However, there were no other preoperative ECGs located in our medical records or in the medical records from other health systems she had visited over the past few years. Interestingly enough, the rate of limb lead reversal in the literature ranges from 0.25% to 1% in the non-intensive care unit setting.
3
,4
We reviewed ECG data at our own institution over the past month and found a similar rate of limb lead reversal (0.44%). Therefore, although it is conceivable that limb lead reversal was also present during our patient's preoperative ECG, it would be, tragically, an ironic coincidence to have occurred in this patient with such a malrotated heart due to an enormous hiatal hernia.Furthermore, the tall R waves in the pre-operative ECG precordial leads cannot be explained solely by limb lead reversal and should still prompt further investigation.
1
Although limb lead reversal may have been present during the initial ECG, it does not undermine our original intent to highlight the value of a non-invasive and cost-effective test, and the importance of considering a broad differential, even across multiple organ systems.References
- Large hiatal hernia manifesting as dextrocardia on electrocardiogram.Am J Med. 2022; 135: 57-59
- Dynamic electrocardiographic changes due to cardiac compression by a giant hiatal hernia.Intern Med. 2005; 44: 136-140
- Electrocardiographic artifacts due to electrode misplacement and their frequency in different clinical settings.Am J Emerg Med. 2007; 25: 174-178
- Artificial neural networks for recognition of electrocardiographic lead reversal.Am J Cardiol. 1995; 75: 929-933
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Footnotes
Funding: None.
Conflict of Interest: None.
Authorship: Both authors had access to the data and a role in writing this manuscript.
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