Teaching electrocardiogram interpretation

Abstract

The subject addressed here permits me to acknowledge my teachers and mentors in electrophysiology and electrocardiography. The first of these is Robert Grant, known to me only through his magisterial book on spatial vectorelectrocardiography. Electrocardiograms (ECGs) could be displayed as 3-dimensional arrows, which are quite difficult to draw. His technique sprung out of contemplation of the standard 12-lead tracing. But simultaneously, vectorcardiography photographed from an oscilloscope as a 3-plane interrupted vector loop was being hatched into limited clinical practice. There were opposing advocacies for the cube, tetrahedron, and Frank system—the latter remaining victorious. In some degree, the oscilloscopic approach to vector concepts blunted Grant’s influence. A later reason for the neglect of his approach: echocardiography. It seemed to promise the localization of lesions or infarcts in the 3-dimensional heart. The real marriage partner of spatial vector-electrocardiography should come with the fruition of cardiac magnetic resonance imaging. My first personal mentor was David Littmann in Boston, whose forte was the ST segment and T wave. Next came Hans Hecht, who made cellular potentials as subjects of clinical discussion as opposed to remote bench inquiry. He and I became deeply involved in the redefinition of the AV junction. A year with Gordon Moe and Carlos Mendez brought to clinical life such notions as electrotonic effect, the cumulative effect of frequency, functional block, electrical occlusion of a conducting pathway, supernormality, and the various types of refractory period. I acquired an enormous respect for the Mexican contributions to both clinical electrocardiography and research techniques (such as the double-dog preparation of Jesus Alanis). Alfred Pick and Richard Langendorf 9 taught me rhythm analysis and such concepts as concealed conduction. I spent a splendid sabbatical year in Paris with Phillipe Coumel, studying atrial vulnerability with Patrick Attuel.