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ECG IN CONGENITAL
HEART DISEASE
LEAVE SOME SPACE FOR GREEN
ECG IN CHD
• ACYANOTIC CHD
• CYANOTIC CHD
Acyanotic
CHD
Without
shunt(normal or
decreased
pulmonary flow)
Right side of heart Left side of heart
↑ PBF
Atrial
Ventri...
II° ASD
• Sinus arrhythmia
• Clockwise loop with vertical axis
• Right axis with PAH
• Left-axis deviation : Holt-Oram syn...
• Wide QRS
• RBBB
• R’ In v1 and AVR is slurred
• Crochetage-specific for ASD if present in all inferior leads
• SND occur...
CROCHETAGE SIGN:R WAVE NOTCH IN ALL INFERIOR LEADS
FOLLOW UP
• PAH
rsR’ gives way to R in v1
Signs of PAH: RAD/RVH
• After surgery R may revert to rsR’ in 40% of
patients
ORIGINAL AND MODIFIED METHODS OF
DEFINING THE BUTLER-LEGGETT SCORE
I°ASD
• Counterclockwise loop
• LAD
• PR prolongation
• RVH- tall R in v1,deep s in v6
• Left A-V valve regurgitation:LVH
...
I° ASD
ASD ALOGARITHM
ASD
Clockwise loop
II° ASD
P -wave axis
normal
Crochetage+
SV ASD
P- wave axis
superior
Crochetage+
Counter...
VSD
•Location
•Hemodynamic burden
•Associated anomalies
•Typical features
LV volume overload
Progressing to BVH
LOCATION
PERIMEMBRANOUS
VSD
INLET VSD MULTIPLE VSD
With septal aneurysm-left
axis deviation
Counterclockwise loop,
LAD and...
HEMODYNAMICS
• Accurately reflects underlying hemodynamics
• Restrictive & small-no changes
• Deep s in right precordial l...
ASSOCIATED ANAMOLIES
• PS-early transition
• AR-marked LVH in presence of restrictive VSD-DEEP Tall Deeply
inverted T and ...
CONDUCTION DEFECTS
• PR prolongation
Inlet VSD
ECDS
DORV
L-TGA
• Septal aneurysm-AF,AFLU,PAT,CHB/Axis change
• POST OP-RBB...
GERBODES’ DEFECT
• Tall peaked p waves and RAE from infancy,
• PR prolongation
• rsr’ in v1,terminal r in avr and V3r –RV ...
CONGENITALLY CORRECTED
TRANSPOSITION
• The AV node is displaced outside of Koch’s triangle, anterior and
slightly more laterally
• An elongated His bundle exte...
• Conduction system
• QRS patterns
• Modifications of P,QRS,ST,T segments
TYPICAL
• Reversal of the normal Q-wave pattern in the precordial leads: Q waves
are present in the right precordial leads...
• 75% have AV conduction abnormalties
• 30% have complete heart block
• Incidence of complete heart block increases by 2% ...
VSD
LEFT AXIS
Clockwise loop-
L-TGA
MULTIPLE
MUSCULAR
Counter clockwise-
DORV
INLET VSD
TRICUSPID ATRESIA
RAD
Severe PAH
VSD
LVH
MODERATELY
RESTRICTIVE
WITH RAE-
GERBODES
BVH
NONRESTRICTIVE
NONRESTRICTIVE-
BVH
Q IN LATERAL
LEADS
PRESENT-simple
VSD ABSENT-LTGA
PDA
• SIMILAR TO VSD
• QRS axis
• RAD- infants with respiratory distress
• Superior/extreme left-Rubella syndrome
AP WINDOW
• SIMILAR TO non restrictive VSD
D-MALPOSED GA
• P wave abnormality- if RA recieves shunt or TR develops
• PR prolongation is seen
• CHB can develop
• QRS ...
WITHOUT SHUNT: NORMAL OR
DECREASED PULMONARY FLOW
• Right side of heart
Valvular PS
DCRV
Peripheral PS
VALVULAR PS
Tall monophasic R or qR in v1
Right axis deviation
Strain pattern in right precordial leads
SEVERITY OF PS
MILD MODERATE SEVERE
 Normal in 30%-60% of cases
 Right axis deviation<100°
 R in v1<10-15mm
 Upright r...
PS SPECIAL
• PS with extreme right axis deviation with splintered QRS and QS in inferior leads-
dysplastic PS of Noonan sy...
DCRV
• RVH can be present
• But in 40% of cases upright T in v3R can be the only finding
ASD WITH PS
• Non restrictive ASD and mild PS
• like ASD
• RVH will be disproportionate
• QRS axis is vertical or rightwar...
NORMAL OR ↓ PBF
• Left side of heart
Coarctation of aorta
Cortriatriatum
Congenital MS
Congenital AS
COARCTATION
• LAE in adults, LVH-tall R waves and low flat inverted T waves
• Deeply coved ST segments-AS –bicuspid aortic...
INTERRUPTION OF AORTIC ARCH
• Peaked right atrial p waves and RVH-infants
• BVH gradually develops
COR TRIATRIATUM
SHONES COMPLEX
ALOGARITHM FOR ACYANOTIC CHD:STEP I
• Which chamber is enlarged
• Step -2-suppose it is RV
• Step-3-is it volume overload(...
STEP II
 Suppose it is LV
 Is it LVH alone/BVH?
 LVH alone?
 volume/pressure?
 volume overload
 Moderately restricti...
• BVH
Nonrestrictive VSD
Large PDA
AP window
RSOV
L-TGA
• q in lateral leads/v1 : lateral leads-simple VSD,PDA,RSOV
• q in...
DORV
DORV
• Left axis deviation with counter clockwise loop
• QRS duration is normal
• RVH is obligatory-tall R in v1
• Deep s ...
CYANOTIC AND ↑ PBF
 Transposition physiology
D-TGA
• D-TGA nonrestrictive VSD with tricuspid atresia
• DORV with sub pulm...
CYANOTIC AND ↓ PBF
• Dominant LV
Tricuspid atresia
Ebstein’ anomaly
Single ventricle –LV type with PS
• TGA (VSD and LVOTO...
CYANOTIC AND ↑ PBF
• D-TGA: conal inversion
• right and anterior aorta
• TGA (IVS or small VSD) with increased PBF and sma...
• Typical feature is RAD with RVH/BVH
• one third of infants with large VSD have normal QRS axis for age.
• Left-axis devi...
TGA WITH NON RESTRICTIVE ASD
• Initial normal ECG
• Developing into RAD with RVH
• LV not prominent
TGA NONRESTRICTIVE VSD
• RAD
• Biventricular hypertrophy
• As PAH increases it evolves into pure RVH
TGA WITH SUB PULMONIC OBSTRUCTION
• Pure RAD with RVH
DORV WITH SUB AORTIC VSD WITH PS
• Peaked right atrial P waves
• Right ventricular hypertrophy
• Important
• Distinction f...
TAUSSIG BING ANAMOLY
TRUNCUS
• Tall peaked right atrial p waves
• Bifid left atrial p waves
• Left axis deviation-increased pulmonary blood flo...
COMMON ATRIUM
TAPVC
• Resembles secundum ASD
• Vertical/right axis
• RVH-common feature
• RAE-present only in non obstructive type
TRICUSPID ATRESIA
VAN PRAAGH AND ASSOCIATES- 1971
 tricuspid atresia
 First classification
 morphology of the tricuspid valve
 (a) muscu...
TRIUSPID ATRESIA BY KUHNE
ECG
• Cyanotic child
• LAD
• Left ventricular hypertrophy
• Type1- adult pattern of progression
• RAE
TYPE -2
• Usually non restrictive VSD
• Normal or vertical axis
• LAE and RAE
HYPOPLASTIC LEFT HEART
• Always RVH
• qR pattern
• Left precordial R waves are diminutive
• Deep S waves are usually seen ...
SINGLE VENTRICLE
• BVH common
• RVH
• LVH
• Stereotype QRS
90% ARE LV MORPHOLOGY INVERTED OUT
LEFT CHAMBER
Non inverted outlet chamber include left axis deviation, left ventricular...
BVH
• Biventricular Hypertrophy (difficult ECG diagnosis to make)
• R/S ratio in V5 or V6 < 1
• S in V5 or V6 > 6 mm
• RAD...
ESTES CRITERIA FOR LVH
>5 SURE,>4 PROBABLY
I AM NOT BE 100% ENTERTAINING
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
Ecg in congenital heart disease
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Ecg in congenital heart disease

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ECG in congenital heart diseases

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Ecg in congenital heart disease

  1. 1. ECG IN CONGENITAL HEART DISEASE
  2. 2. LEAVE SOME SPACE FOR GREEN
  3. 3. ECG IN CHD • ACYANOTIC CHD • CYANOTIC CHD
  4. 4. Acyanotic CHD Without shunt(normal or decreased pulmonary flow) Right side of heart Left side of heart ↑ PBF Atrial Ventricular Aortic root right side of heart Aortopulmonary level
  5. 5. II° ASD • Sinus arrhythmia • Clockwise loop with vertical axis • Right axis with PAH • Left-axis deviation : Holt-Oram syndrome/LAHB • RAE • P wave axis-inferior and to left with upright p in inferior leads • PR interval:may be prolonged,intra-atrial/H-V conduction delay-first- degree AV block
  6. 6. • Wide QRS • RBBB • R’ In v1 and AVR is slurred • Crochetage-specific for ASD if present in all inferior leads • SND occurs as early as 2 years of age • Atrial fibrillation,Atrial flutter • PAT
  7. 7. CROCHETAGE SIGN:R WAVE NOTCH IN ALL INFERIOR LEADS
  8. 8. FOLLOW UP • PAH rsR’ gives way to R in v1 Signs of PAH: RAD/RVH • After surgery R may revert to rsR’ in 40% of patients
  9. 9. ORIGINAL AND MODIFIED METHODS OF DEFINING THE BUTLER-LEGGETT SCORE
  10. 10. I°ASD • Counterclockwise loop • LAD • PR prolongation • RVH- tall R in v1,deep s in v6 • Left A-V valve regurgitation:LVH • Notching of s wave upstrokes in inferior leads
  11. 11. I° ASD
  12. 12. ASD ALOGARITHM ASD Clockwise loop II° ASD P -wave axis normal Crochetage+ SV ASD P- wave axis superior Crochetage+ Counterclockwise Loop I° ASD LAD/Notching of s in inf leads LVH/LAE
  13. 13. VSD •Location •Hemodynamic burden •Associated anomalies •Typical features LV volume overload Progressing to BVH
  14. 14. LOCATION PERIMEMBRANOUS VSD INLET VSD MULTIPLE VSD With septal aneurysm-left axis deviation Counterclockwise loop, LAD and prolonged PR interval Clockwise loop with left axis deviation
  15. 15. HEMODYNAMICS • Accurately reflects underlying hemodynamics • Restrictive & small-no changes • Deep s in right precordial leads,R in v5,v6-lv volume overload • Moderately restrictive-LVH+LAE • Non restrictive-BVH and Katz -Wetchel,RAD • EISENMENGER-Moderately peaked p waves,RAD,tall monophasic R in v1,deep S in left precordial leads
  16. 16. ASSOCIATED ANAMOLIES • PS-early transition • AR-marked LVH in presence of restrictive VSD-DEEP Tall Deeply inverted T and coved ST segments in left precordial leads • DORV,L-TGA-Similar to VSD
  17. 17. CONDUCTION DEFECTS • PR prolongation Inlet VSD ECDS DORV L-TGA • Septal aneurysm-AF,AFLU,PAT,CHB/Axis change • POST OP-RBBB(ventricular approach)
  18. 18. GERBODES’ DEFECT • Tall peaked p waves and RAE from infancy, • PR prolongation • rsr’ in v1,terminal r in avr and V3r –RV volume overload • LV volume overload • Increased incidence of arrhythmias • Pathognomonic-RAE with LV volume overload
  19. 19. CONGENITALLY CORRECTED TRANSPOSITION
  20. 20. • The AV node is displaced outside of Koch’s triangle, anterior and slightly more laterally • An elongated His bundle extends toward the site of fibrous continuity between the right-sided mitral valve and pulmonary artery(posterior) • It courses across the anterior rim of the pulmonary valve and continues along the superior border of VSD
  21. 21. • Conduction system • QRS patterns • Modifications of P,QRS,ST,T segments
  22. 22. TYPICAL • Reversal of the normal Q-wave pattern in the precordial leads: Q waves are present in the right precordial leads but are absent in the left precordial leads • Clockwise loop • Left axis deviation • Upright T waves in all precordial leads –side by side orientation of both ventricles
  23. 23. • 75% have AV conduction abnormalties • 30% have complete heart block • Incidence of complete heart block increases by 2% /yr • Long bundle length –difficult to localise site of block • Sub pulmonic stenosis develops-axis will be right • In even in prescence of left AV valve regurgitation and volume overload-no Q waves in left precordial leads
  24. 24. VSD LEFT AXIS Clockwise loop- L-TGA MULTIPLE MUSCULAR Counter clockwise- DORV INLET VSD TRICUSPID ATRESIA RAD Severe PAH
  25. 25. VSD LVH MODERATELY RESTRICTIVE WITH RAE- GERBODES BVH NONRESTRICTIVE
  26. 26. NONRESTRICTIVE- BVH Q IN LATERAL LEADS PRESENT-simple VSD ABSENT-LTGA
  27. 27. PDA • SIMILAR TO VSD • QRS axis • RAD- infants with respiratory distress • Superior/extreme left-Rubella syndrome
  28. 28. AP WINDOW • SIMILAR TO non restrictive VSD
  29. 29. D-MALPOSED GA • P wave abnormality- if RA recieves shunt or TR develops • PR prolongation is seen • CHB can develop • QRS axis is normal or rightward • All 4 chambers enlarged-into RA • RVH,LAE,LVH-into RV • Only LA,LV-rupture into LA • LVH is seen,RVH is seen ,but it occyurs alone it is due to RVOT obstruction by unruptured aneurysm
  30. 30. WITHOUT SHUNT: NORMAL OR DECREASED PULMONARY FLOW • Right side of heart Valvular PS DCRV Peripheral PS
  31. 31. VALVULAR PS Tall monophasic R or qR in v1 Right axis deviation Strain pattern in right precordial leads
  32. 32. SEVERITY OF PS MILD MODERATE SEVERE  Normal in 30%-60% of cases  Right axis deviation<100°  R in v1<10-15mm  Upright right precordial T waves after 4 days of age maybe only sign  Gradient of 40mm mmHg  RVSP<50% of LVSP   r/s in v1>4:1  rsR’ or a small r is present on upstroke of R’  R in v1 <20mm  50%-upright T aves  Gradient>40 mm Hg  RVSP>50% of LVSP  RAD>150°  Monophasic R or Qr  R >20mm  P in lead 2 tall and peaked,in v1 terminal force is written by right atrial dilatation  P maybe negative  RVSP=LVSP or more  Gradient >80 mm Hg  Deep inverted T waves ,ST depression beyond v2 and R in v1 >20mm-RVSP>LVSP
  33. 33. PS SPECIAL • PS with extreme right axis deviation with splintered QRS and QS in inferior leads- dysplastic PS of Noonan syndrome. • Infants with severe stenosis, in whom the right ventricle may be hypoplastic, have a more leftward axis than expected (in the range of +30 to +70 degrees) as well as evidence of left ventricular hypertrophy
  34. 34. DCRV • RVH can be present • But in 40% of cases upright T in v3R can be the only finding
  35. 35. ASD WITH PS • Non restrictive ASD and mild PS • like ASD • RVH will be disproportionate • QRS axis is vertical or rightward • rsR’ in v1-R’will be taller than that due to isolated ASD • Severe PS with PFO-resembles isolated severe PS
  36. 36. NORMAL OR ↓ PBF • Left side of heart Coarctation of aorta Cortriatriatum Congenital MS Congenital AS
  37. 37. COARCTATION • LAE in adults, LVH-tall R waves and low flat inverted T waves • Deeply coved ST segments-AS –bicuspid aortic valve • Q waves in left precordial leads suggests AR • Symptomatic infants-RAE ,RAD with RVH • LV strain pattern in infancy is indication for surgery
  38. 38. INTERRUPTION OF AORTIC ARCH • Peaked right atrial p waves and RVH-infants • BVH gradually develops
  39. 39. COR TRIATRIATUM
  40. 40. SHONES COMPLEX
  41. 41. ALOGARITHM FOR ACYANOTIC CHD:STEP I • Which chamber is enlarged • Step -2-suppose it is RV • Step-3-is it volume overload(rsr’/rsR’)or pressure overload(monophasic R/qR) • Step-4-volume overload-ASD/RSOV • Pressure overload-PS DCRV Infantile coarctation • Cortriatriatum-broad left atrial P waves • Cogenital MS-LAE
  42. 42. STEP II  Suppose it is LV  Is it LVH alone/BVH?  LVH alone?  volume/pressure?  volume overload  Moderately restrictive VSD  PDA  Pressure overload  Coarctation of aorta  Congenital AS  Interrupted .aortic arch  Critical PS of infancy
  43. 43. • BVH Nonrestrictive VSD Large PDA AP window RSOV L-TGA • q in lateral leads/v1 : lateral leads-simple VSD,PDA,RSOV • q in v1,2:L TGA • RA enlargement is present-RSOV
  44. 44. DORV
  45. 45. DORV • Left axis deviation with counter clockwise loop • QRS duration is normal • RVH is obligatory-tall R in v1 • Deep s in V6 • LV volume overload –tall RS complexes in mid precordial leads and tall R in v5/v6 • PAH-clockwise loop with right axis deviation
  46. 46. CYANOTIC AND ↑ PBF  Transposition physiology D-TGA • D-TGA nonrestrictive VSD with tricuspid atresia • DORV with sub pulmonary VSD with NO PS • Tausig Bing • Admixture physiology Common atrium Truncus arteriosus TAPVC
  47. 47. CYANOTIC AND ↓ PBF • Dominant LV Tricuspid atresia Ebstein’ anomaly Single ventricle –LV type with PS • TGA (VSD and LVOTO), with restricted PBF • TGA (VSD and PVOD), with restricted PBF
  48. 48. CYANOTIC AND ↑ PBF • D-TGA: conal inversion • right and anterior aorta • TGA (IVS or small VSD) with increased PBF and small ICSa • TGA (VSD large) with increased PBF and large ICS • TGA (VSD and LVOTO), with restricted PBF • TGA (VSD and PVOD), with restricted PBF
  49. 49. • Typical feature is RAD with RVH/BVH • one third of infants with large VSD have normal QRS axis for age. • Left-axis deviation - typical in TGA with AV canal types of VSD
  50. 50. TGA WITH NON RESTRICTIVE ASD • Initial normal ECG • Developing into RAD with RVH • LV not prominent
  51. 51. TGA NONRESTRICTIVE VSD • RAD • Biventricular hypertrophy • As PAH increases it evolves into pure RVH
  52. 52. TGA WITH SUB PULMONIC OBSTRUCTION • Pure RAD with RVH
  53. 53. DORV WITH SUB AORTIC VSD WITH PS • Peaked right atrial P waves • Right ventricular hypertrophy • Important • Distinction from TOF is presence of counterclockwise loop with slurred s in v5,6,1,avl and broad R in avr and presence of PR prolongation
  54. 54. TAUSSIG BING ANAMOLY
  55. 55. TRUNCUS • Tall peaked right atrial p waves • Bifid left atrial p waves • Left axis deviation-increased pulmonary blood flow • Right axis deviation-decreased pulmonary blood flow • Biventricular hypertrophy
  56. 56. COMMON ATRIUM
  57. 57. TAPVC • Resembles secundum ASD • Vertical/right axis • RVH-common feature • RAE-present only in non obstructive type
  58. 58. TRICUSPID ATRESIA
  59. 59. VAN PRAAGH AND ASSOCIATES- 1971  tricuspid atresia  First classification  morphology of the tricuspid valve  (a) muscular type, (b) fibrous (membranous) type, and (c) Ebstein’s type  modified by him”’ and by Weinberg muscular type constituted 84% membranous type n 8%  The Ebstein’s type in 8%
  60. 60. TRIUSPID ATRESIA BY KUHNE
  61. 61. ECG • Cyanotic child • LAD • Left ventricular hypertrophy • Type1- adult pattern of progression • RAE
  62. 62. TYPE -2 • Usually non restrictive VSD • Normal or vertical axis • LAE and RAE
  63. 63. HYPOPLASTIC LEFT HEART • Always RVH • qR pattern • Left precordial R waves are diminutive • Deep S waves are usually seen in lead V6 • Right atrial enlargement • Right axis deviation • ST segment changes may reflect inadequate coronary perfusion from restriction of retrograde flow through a hypoplastic ascending aortic arch
  64. 64. SINGLE VENTRICLE • BVH common • RVH • LVH • Stereotype QRS
  65. 65. 90% ARE LV MORPHOLOGY INVERTED OUT LEFT CHAMBER Non inverted outlet chamber include left axis deviation, left ventricular hypertrophy, QRS complexes of great amplitude, and stereotyped precordial patterns Inverted outlet chamber include PR interval prolongation, an inferior or rightward QRS axis, absent left precordial Q waves, RS complexes of great amplitude, and stereotyped precordial patterns Right ventricular morphology:Precordial QRS complexes are stereotyped with right ventricular hypertrophy patterns of increased amplitude
  66. 66. BVH • Biventricular Hypertrophy (difficult ECG diagnosis to make) • R/S ratio in V5 or V6 < 1 • S in V5 or V6 > 6 mm • RAD (> 90 degrees)
  67. 67. ESTES CRITERIA FOR LVH >5 SURE,>4 PROBABLY
  68. 68. I AM NOT BE 100% ENTERTAINING

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