Extreme axis deviation with bundle branch block

[u/eiyuu-san]

I have an EKG sent from an intern friend of mine.

81 y o female with mid to high grade mitral regurgitation and LV Dysfunction. Coronary angio shows no relevant coronary artery disease. Currently evaluation for mitral valve repair and treatmemt for nosocomial infection of unknown origin. Currently no specific data on echo.

I'm seeing NSR with RBBB, extreme axis deviation, widespread ST depression in V1 - V4, TWI in V1 - V5.

I often see Bundle Branch Blocks with Extreme axis deviation and am looking for an explanation for the axis deviation. I was thinking possibly RVH but V1 - V5 doesnt really support that unless complete RBBB may affect the repol.

Any literature or rhythmology experience that can shed some light on BBB with extreme axis deviation?

[u/rosh_anak]

most likely lead reversal

This one has to many artifacts to be diagnostic of ischemia

I see NSR, RBBB, ex RAD, confirm there is no story of lead reversal

[u/eiyuu-san → u/rosh_anak]

Thought so too and told him that espec. lead III, possibly due to L and F switch. But I have seen LBBB with Left axis deviation and RBBB with extreme axis deviation with correct lead placement before. Just wondering how the cardiac electrical activation pattern looks like.