Giant T-wave inversion is defined as T-wave inversion that is greater than 10 mm in any electrocardiography lead, whereas global T-wave inversion refers to inverted T waves in all standard leads except augmented voltage right arm (aVR). The accompanying image exhibits these uncommon electrocardiography findings. Anesthesiologists often have to decide whether additional investigations are required in patients who exhibit T-wave inversions in the perioperative period. Nonspecific T-wave inversions occur commonly in surgical patients and are clinically benign.1  In contrast, giant negative T waves occur in specific conditions such as left main or equivalent myocardial ischemia and apical hypertrophic cardiomyopathy.2  Regardless of the degree of T-wave inversion, concomitant presence of chest pain, dyspnea, and ST-segment changes should prompt further cardiac work-up and consultation.1 

Giant negative T waves in precordial leads V4–V6 in conjunction with tall R waves are frequently found in apical hypertrophic cardiomyopathy. Interestingly, the degree of T-wave inversion correlates well with the severity of apical hypertrophy. Echocardiography is corroborative (Supplemental Digital Content, http://links.lww.com/ALN/B940).2 

Apical hypertrophy often severely decreases left ventricular compliance and chamber size. A small and stiff left ventricle impairs diastolic filling enough to compromise stroke volumes despite preserved systolic function. This complicates anesthetic care. Although overzealous fluid administration precipitates cardiogenic pulmonary edema, hypovolemia markedly decreases stroke volume, causing precipitous hypotension. Optimization of hemodynamics relies on preservation of atrial kick, control of heart rate, judicious preloading, and use of vasopressors. Invasive arterial monitoring and transesophageal echocardiography help in decision-making when substantial fluid shifts are anticipated.3 

Competing Interests

The authors declare no competing interests.

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