右脚ブロック及び不完全右脚ブロックのベクトル心電圖學的分析 : 並びに僧帽瓣膜疾患時rSR'-V_1 patternとの比較檢討

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1) A study is made of the VCG patterns using Grishman's and Kimura's cube system of 48 cases with complete right bundle branch block (RBBB) and 32 cases with incomplete RBBB, in comparison with 17 cases of mitral valvular disease showing rSR'-V_1 pattern (QRS duration <0.11 second) in the ECG (Table I). Relations between the configuration of the QRS loop and the subtype of RBBB in the ECG or the underlying disease, and those between the configuration of the T loop or S-T vector and the ventricular gradient are analysed.2) There is a certain relationship between the orientation of the QRS loop in the VCG and the subtype (following the classification by Bayley, Pardee, and Lepeschkin) of RBBB in the ECG in the frontal plane. In the present study, the aforementioned criteria of the classification is applied also for incomplete RBBB. Eight cases which resemble Subtype IVa, but having narrow S_III, are classified tentatively as Subtype IVa' (Fig. 1).The main part of the QRS loop of Grishman vector is mostly oriented to the right and inferiorly or to the left and inferiorly in Subtype I, to the left and inferiorly in Subtype II, III, IVa and IVa', and to the left and superiorly in Subtype IVb, Va and Vb, and that of Kimura vector is mostly oriented to the right and inferiorly or to the left and inferiorly in Subtype I and II, to the left and inferiorly or to the left and superiorly in Subtype III, to the left and inferiorly in Subtype IVa, IVa', IVb, and extended superiorly and inferiorly in Subtype Va and Vb.The terminal appendage of Grishman vector is mostly oriented to the right and superiorly or to the right and inferiorly in Subtype I and II, and to the right and superiorly in the other subtypes. The terminal appendage or terminal portion of Kimura vector is mostly oriented to the right and superiorly or to the right and inferiorly in Subtype I and III, to the right and inferiorly in Subtype II, and to the right and superiorly in the other subtypes. But the direction of inscription or the configuration of the QRS loop in the frontal and horizontal planes in each case is closely related to the underlying disease, and is different although these cases are classified into the same subtype.3) Group L.-In this group, 30 cases with hypertension or with left ventricular enlargement on the x-ray are included. The main part of the QRS loop of Grishman vector (Table III) is mostly inscribed in a counterclockwise direction in the frontal plane and in the horizontal plane, and the terminal appendage is mostly inscribed in a counterclockwise direction in the horizontal plane (Fig. 4,6,7). The main part of the QRS loop of Kimura vector (Table V) is mostly in a counterclockwise direction in the frontal plane (Fig. 17,19,21,22).Appedix : In five cases with myocardial infarction and RBBB, the initial portion and the main part of the QRS loop of Grishman vector are displaced to the opposite direction of the infarcted area, and the main part of the QRS loop is mostly inscribed in a counterclockwise direction in the frontal plane (Fig. 8,9). The configuration of the QRS loop of myocardial infarction of Kimura vector showing nearly the same configuration as that of Grishman vector. But in the cases with anterior infarction, the initial portion of the QRS loop of Kimura vector is sharply displaced to the opposite direction of the infarcted area (Fig. 23,24).4) Group N.-In this group 19 cases without signs of heart disease except for RBBB are included. The main part of the QRS loop of Grishman vector is mostly inscribed in a clockwise direction in the frontal plane, and in a counterclockwise direction in the horizontal plane, and the terminal appendage is mostly inscribed in a counterclockwise direction in the horizontal plane (Fig. 2,10,11). The cases, of which the main part of the QRS loop is inscribed in a clockwise direction in the horizontal plane, have no other signs of right ventricular hypertrophy.The main part of the QRS loop of Kimura vector is inscribed in a clockwise direction in the frontal plane, for all cases (Fig. 18,25). The counterclockwise direction of inscription for the main part of the QRS loop of Kimura vector in the frontal plane may be a sign suggestive of an additional development of left ventricular hypertrophy on RBBB. This sign is encountered not in Group N, but in Group L.5) Group C.-In this group, 21 cases probably with atrial septal defect, are included. Three of the cases are confirmed on surgical operation or post-mortem examination.The main part of the QRS loop of Grishman vector is mostly inscribed in a counterclockwise direction and the terminal appendage is mostly inscribed in a clockwise direction in the horizontal plane (Fig. 5,12,13). The configuration is different from a transitional form from the normal form to the right ventricular hypertrophy form. In this transitional form, the distal portion of the QRS loop is inscribed in a counterclockwise direction, and the proximal portion is inscribed in a clockwise direction, but the terminal portion is not so extended to the right of the origin, as in the cases of Group C. In this form, prior to the extension of the terminal portion to the right, the main portion of the QRS loop is clearly inscribed in a clockwise direction (Fig. 32). On the other hand, in Group C, the main part of the QRS loop is still inscribed in a counterclockwise direction, despite the extension of the terminal appendage to the right. It is suggested that the rSR'-V_1 pattern in the ECG of Group C is influenced by a different mechanism from the trasitional form from the normal form to the right ventricular hypertrophy form.The main part of the QRS loop of Kimura vector is mostly inscribed in a clockwise direction (Fig. 20,26) except for 5 cases in the frontal plane (Fig. 27). The long axis of the QRS loop of Kimura vector is mostly oriented to the right.6) Group M.-In this group, 22 cases with mitral valvular disease are included. In 5 cases of mitral valvular disease showing complete RBBB, the main part of the QRS loop of Grishman vector is mostly inscribed in a clockwise direction in the frontal plane, and in the horizontal plane. The terminal appendage is directed to the right and anteriorly and is inscribed in a clockwise direction in the horizontal plane (Fig. 3). The main part of the QRS loop of Kimura vector is mostly inscribed in a clockwise direction in the frontal plane (Fig. 28).In 17 cases of mitral valvular disease showing rSR'-V_1 pattern (QRS duration <0.11 second) in the ECG, the main part of the QRS loop is mostly inscribed in a clockwise direction in the frontal plane, and very narrow in the horizontal plane and is inscribed in a clockwise direction. The terminal portion is not extended remarkably to the right and anteriorly (Fig. 15). Some maintain an opinion that rSR'-V_1 pattern in mitral valvular disease is resulted from a hypertrophy of both ventricles. The foregoing VCG figure differs considerably from the transitional form from the normal form to the right ventricular hypertrophy form. The main part of the QRS loop of Kimura vector is mostly inscribed in a clockwise direction in the frontal plane, and the long axis of the QRS loop is mostly oriented to the right (Fig. 29).7) The characteristics of each group are summarized as follows (Fig. 16,30) : Group L.-The main part of the QRS loop and the terminal appendage of Grishman vector is mostly inscribed in a counterclockwise direction in the horizontal plane, and the main part of QRS loop of Kimura vector is mostly inscribed in a counterclockwise direction in the frontal plane.Group N.-The main part of the QRS loop and the terminal appendage of Grishman vector is mostly inscribed in a counterclockwise direction in the horizontal plane, and the main part of the QRS loop of Kimura vector is mostly inscribed in a clockwise direction in the frontal plane.Group C.-The main part of the QRS loop of Grishman vector is mostly inscribed in a counterclockwise direction, and the terminal appendage is mostly in a clockwise direction in the horizontal plane. The main part of the QRS loop of Kimura vector is mostly inscribed in a clockwise direction in the frontal plane.Group M.-The main part of the QRS loop and the terminal portion of Grishman vector is inscribed in a clockwise direction in the horizontal plane. The main part of the QRS loop of Kimura vector is inscribed in a clockwise direction in the frontal plane.It is concluded that the VCG tracings of RBBB on a combined application of Grishman's and Kimura's cube system can find a favorable approach to the underlying disease.8) Most of the cases with the T loop of Grishman vector which is described below reveal the normal ventricular gradient (Table VI, VII) : i) what is directed to the left and anteriorly or to the left and posteriorly.ii) a rod-shaped one, or the striped one, of which the centrifugal limb and the centripetal limb are overlapped to each other, showing no protrusion from the opposite direction of the terminal portion of the QRS loop.iii) a ring-shaped one, with an adverse direction of inscription to the terminal portion of the QRS loop in 2 planes or less, showing no protrusion in the opposite direction of the terminal portion of the QRS loop.Most of the cases with the T loop of Grishman vector which is described below reveal the abnormal ventricular gradient.i) what is directed to the right and posteriorly or to the right and anteriorly.ii) a rod-shaped one, showing a protrusion from the opposite direction of the terminal portion of the QRS loop.iii) a ring-shaped one, with an adverse direction of inscription to the terminal portion of the QRS loop in 2 planes or less, but with a protrusion in the opposite direction of the terminal portion of the QRS loop.iv) a ring-shaped one, with an adverse direction of inscription to the terminal portion of the QRS loop in all 3 planes.v) a point-like one.
社団法人日本循環器学会の論文
1959-08-20

右脚ブロック及び不完全右脚ブロックのベクトル心電圖學的分析 : 並びに僧帽瓣膜疾患時rSR'-V_1 patternとの比較檢討

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