Limb Lead Reversal

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Between 0.4 and 4% of ECG’s obtained in various settings demonstrate features of lead misplacement. Lead misplacement may either obscure important findings or simulate the appearance of ectopic rhythms, conduction disturbances, chamber abnormalities, and ischemia/infarction – resulting in unnecessary and potentially invasive testing. The key ECG findings suggestive of lead misplacement are dependent on the leads involved. The relationship between limb leads and surface electrodes are defined by Einthoven’s Triangle.

 

ECG changes resulting from limb lead reversal.

Examples

ECG Showing Limb Lead Reversal

Limb Lead Reversal

The "northwest" axis, abnormal P wave axis (i.e., upgoing in aVR), and concordance of complexes in aVR and V6 strongly suggest limb lead reversal.
ECG Showing 43-LLR

Limb Lead Reversal

The presence of negative P-QRS complexes in lead I is unusual for this young patient with no significant medical history. If the finding were to represent a real underlying condition (such as severe pulmonary disease), some corroboration in the precordial leads would be expected. Moreover, the bizarre positive P-QRS complexes in aVR suggest an alternative diagnosis – LA/RA limb lead misplacement.

References

  1. Rudiger, A., Hellermann, J. P., Mukherjee, R., Follath, F. & Turina, J. Electrocardiographic artifacts due to electrode misplacement and their frequency in different clinical settings. Am J Emerg Medicine 25, 174–178 (2007).
  2. Batchvarov, V. N., Malik, M. & Camm, A. J. Incorrect electrode cable connection during electrocardiographic recording. Ep Europace 9, 1081–1090 (2007).
  3. Harrigan, R. A., Chan, T. C. & Brady, W. J. Electrocardiographic Electrode Misplacement, Misconnection, and Artifact. J Emerg Medicine 43, 1038–1044 (2012).
  4. Rosen, A. V., Koppikar, S., Shaw, C. & Baranchuk, A. Common ECG Lead Placement Errors. Part I: Limb lead Reversals. Int J Medical Students 2, 92–98 (2014).
  5. Pérez‐Riera, A. R., Barbosa‐Barros, R., Daminello‐Raimundo, R. & Abreu, L. C. Main artifacts in electrocardiography. Ann Noninvas Electro 23, e12494 (2018).