Is it an 'RBBB' ?

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QUESTION 2. Right bundle branch block (RBBB) should be diagnosed on the basis of a widened QRS complex with an R' deflection in V1. These are present but several clues should alert you to the fact that this is not a simple, uncomplicated RBBB:

• The R' deflection only reverts to baseline after about 200ms. This would be remarkable in an uncomplicated RBBB. A more likely conjecture is that there is marked ST segment elevation.
• Even more important is the presence of Q waves in V1 and V2. A right bundle branch block cannot alter the initial QRS deflection.

In the clinical context of a man with severe vascular disease, a normal-sized heart on chest x-ray, and a poor ejection fraction, one should be extremely concerned about recent anterior (septal) myocardial infarction.

Echocardiography showed an akinetic septum, hypokinetic apex, and thrombus in the left ventricle. Electrocardiograms performed two days and eleven days after the first ECG are shown in Figs 6 and 7.

Fig 6. ECG taken two days after the first

Fig 7. .. and after 11 days

QUESTION 3. No. The foot needs to come off. It's also crazy to perform major surgery like an aortobifemoral graft in someone with a recent myocardial infarction and left-ventricular dysfunction. In the actual case, after extensive discussion the surgeons still refused to remove the foot, but agreed to do a lesser procedure (an axillo-bifemoral graft) and after struggling ineffectually with antibiotic therapy for a week, eventually amputated the foot.