Situs Soltius with Dextrocardia

I thought this was just an ordinary or classic strip but looking at it I found some twist...

Starting with the easy ones -

THE QRS

In the precordial leads - the R waves are taller in V1 and becoming smaller as we go from V2 to V6 (reversal of R wave progression). So looks like the leads are reversed but not. Also it seems that heart is going away from the leads. This is dextrocardia.

There are also Q waves noted in V4-V6. This is due to the septal depolarization with a LEFT TO RIGHT direction.

In cardiac malposition, the ECG can be used to localized the ventricle based on (red arrow) septal depolarization (producing Q waves in the precordial leads) In this case, the LV is on the left side/ (confusing? LV on the left in dextrocardia).

The Q wave in I may be due to RVH.

THE P WAVES

The P waves seems to be coming from the normal direction (axis about 45) or upright in I and aVF. RA is on the right side (RA to the right of LA or situs solitus of the atria)

Thus this fits the pattern of:

Situs soltius with dextrocardia
RVH (Q waves in I)

(sorry cannot show here cxr of this case)

The characteristic features are:

Upright P waves in I, normal P wave pattern in aVR and aVL
Major precordial QRS voltage lies in the right hemithorax.

**** You do not see the classsic inversions because this is not dextrocardia with situs inversus or mirror-image dextrocardia.

Good read - http://circ.ahajournals.org/content/116/23/2726.full.pdf+html

Here is also a nice slide set presentation for cardiac malposition - http://www.slideshare.net/smcmedicinedept/ecg-cardiac-malpositions