ECG signs of both right and left ventricular strain are observed simultaneously.

ECG 1. The ECG above belongs to a 63 years-old woman with angiographically documented normal coronary arteries.
The rhythm is atrial fibrillation. There is right bundle branch block (RBBB).
Echocardiography showed mechanical mitral valve prosthesis with 3rd degree (severe) paravalvular mitral regurgitation.
Severe mitral regurgitation and systemic hypertension cause left ventricular strain in this patient.
Echocardiography also showed pulmonary hypertension with 4th degree (severe) tricuspid regurgitation.
The right ventricle and the right atrium were dilated, and the the right ventricle was severely hypokinetic.
Pulmonary hypertension and severe tricuspid insufficiency cause right ventricular strain in this patient.
T wave negativity in chest leads do not resemble the symmetrically negative T waves in myocardial ischemia.

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