ECG in Congenital Heart Disease: Difference between revisions

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Congenital Heart Disease can result in ECG changes, often related to atrial or ventricular overload and  enlargement. Below a list of relatively common forms of congenital heart disease and their potential ECG changes. Adapted from Khairy et al.<cite>khairy</cite>
==Secundum atrial septal defect==
==Secundum atrial septal defect==
Information about [[w:Atrial_septal_defect|Secundum atrial septal defec on Wikipedia (external link)]]
*[[Rhythm]]: normal sinus rhythm, increased risk of AF with age
*[[Rhythm]]: normal sinus rhythm, increased risk of AF with age
*[[Conduction|PR interval]]: first degree AV block in 6-19%
*[[Conduction|PR interval]]: first degree AV block in 6-19%
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==Ventricular Septal Defect==
==Ventricular Septal Defect==
Information about [[w:Ventricular_septal_defect|Ventricular Septal Defect on Wikipedia (external link)]]
*[[Rhythm]]: normal sinus rhythm, PVCs
*[[Rhythm]]: normal sinus rhythm, PVCs
*[[Conduction|PR interval]]:  
*[[Conduction|PR interval]]: Normal or mild &uarr;; 1° AVB 10%
*[[Heart axis|QRS axis]]:  
*[[Heart axis|QRS axis]]: RAD with BVH; LAD 3% to 15%
* QRS Configuration:  
* QRS Configuration: Normal or rsr&acute;; possible RBBB
* Atrial Enlargement:  
* Atrial Enlargement: Possible RAE&plusmn;LAE
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]:  
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: BVH 23% to 61%; RVH with Eisenmenger
*Particularities:  
*Particularities: Katz-Wachtel phenomenon


==AV canal defect==
==AV canal defect==
*[[Rhythm]]:  
Information about [[w:Atrioventricular_septal_defect|AV canal defect on Wikipedia (external link)]]
*[[Conduction|PR interval]]:  
*[[Rhythm]]: normal sinus rhythm, PVCs 30%
*[[Heart axis|QRS axis]]:  
*[[Conduction|PR interval]]: 1° AVB &gt;50%
* QRS Configuration:  
*[[Heart axis|QRS axis]]: Moderate to extreme LAD; normal with atypical
* Atrial Enlargement:  
* QRS Configuration: rSr&acute; or rsR&acute;
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]:  
* Atrial Enlargement: Possible LAE
*Particularities:  
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: Uncommon in partial; BVH in complete; RVH with Eisenmenger
*Particularities: Inferoposteriorly displaced AVN


==Patent ductus arteriosus==
==Patent ductus arteriosus==
*[[Rhythm]]:  
Information about [[w:Patent_ductus_arteriosus|Patent ductus arteriosus on Wikipedia (external link)]]
*[[Conduction|PR interval]]:  
*[[Rhythm]]: normal sinus rhythm, &uarr; IART/AF with age
*[[Heart axis|QRS axis]]:  
*[[Conduction|PR interval]]: &uarr; PR 10% to 20%
* QRS Configuration:  
*[[Heart axis|QRS axis]]: Normal
* Atrial Enlargement:  
* QRS Configuration: Deep S V<sub>1</sub>, tall R V<sub>5</sub> and V<sub>6</sub>
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]:  
* Atrial Enlargement: LAE with moderate PDA
*Particularities:  
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: Uncommon
*Particularities: Often either clinically silent or Eisenmenger


==Pulmonary stenosis==
==Pulmonary stenosis==
*[[Rhythm]]:  
Information about [[w:Pulmonary_valve_stenosis|Pulmonary stenosis on Wikipedia (external link)]]
*[[Conduction|PR interval]]:  
*[[Rhythm]]: normal sinus rhythm
*[[Heart axis|QRS axis]]:  
*[[Conduction|PR interval]]: Normal
* QRS Configuration:  
*[[Heart axis|QRS axis]]: Normal if mild; RAD with moderate/severe
* Atrial Enlargement:  
* QRS Configuration: Normal; or rSr&acute;; R&acute; increases with severity
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]:  
* Atrial Enlargement: Possible RAE
*Particularities:  
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: RVH; severity correlates with R:S in V<sub>1</sub> and V<sub>6</sub>
*Particularities: Axis deviation correlates with RVP


==Aortic coarctation==
==Aortic coarctation==
*[[Rhythm]]:  
Information about [[w:Coarctation_of_the_aorta|Aortic coarctation on Wikipedia (external link)]]
*[[Conduction|PR interval]]:  
*[[Rhythm]]: normal sinus rhythm
*[[Heart axis|QRS axis]]:  
*[[Conduction|PR interval]]: Normal
* QRS Configuration:  
*[[Heart axis|QRS axis]]: Normal or LAD
* Atrial Enlargement:  
* QRS Configuration: Normal
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]:  
* Atrial Enlargement: Possible LAE
*Particularities:  
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: LVH, especially by voltage criteria
*Particularities: Persistent RVH rare beyond infancy


==Ebstein’s anomaly==
==Ebstein’s anomaly==
*[[Rhythm]]: NSR; possible EAR, SVT; AF/IART 40%
[[File:E000403.jpg|thumb|300px|ECG from a patient with Ebstein's anomaly showing huge P waves and low amplitude QRS waves. RBBB and T wave inversion are not present on this ECG.]]
[[File:DVA0559.jpg|thumb|300px|ECG from a patient with Ebstein's anomaly]]
Information about [[w:Ebstein's_anomaly|Ebstein's anomaly on Wikipedia (external link)]]
*[[Rhythm]]: normal sinus rhythm, possible EAR, SVT; AF/IART 40%
*[[Conduction|PR interval]]: 1° AVB common; short if WPW
*[[Conduction|PR interval]]: 1° AVB common; short if WPW
*[[Heart axis|QRS axis]]: Normal or LAD
*[[Heart axis|QRS axis]]: Normal or LAD
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*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: Diminutive RV
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: Diminutive RV
*Particularities: Accessory pathway common; Q II, III, aVF, and V<sub>1</sub>–V<sub>4</sub>
*Particularities: Accessory pathway common; Q II, III, aVF, and V<sub>1</sub>–V<sub>4</sub>
{{clr}}


==Surgically repaired TOF==
==Surgically repaired TOF==
*[[Rhythm]]: NSR; PVCs; IART 10%; VT 12%
Information about [[w:Tetralogy_of_Fallot|Surgically repaired TOF on Wikipedia (external link)]]
*[[Rhythm]]: normal sinus rhythm, PVCs; IART 10%; VT 12%
*[[Conduction|PR interval]]: Normal or mild &uarr;
*[[Conduction|PR interval]]: Normal or mild &uarr;
*[[Heart axis|QRS axis]]: Normal or RAD; LAD 5% to 10%
*[[Heart axis|QRS axis]]: Normal or RAD; LAD 5% to 10%
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==Congenitally corrected TGA==
==Congenitally corrected TGA==
*[[Rhythm]]: NSR
Information about [[w:Levo-Transposition_of_the_great_arteries|Congenitally corrected TGA on Wikipedia (external link)]]
*[[Rhythm]]: normal sinus rhythm
*[[Conduction|PR interval]]: 1° AVB &gt;50%; AVB 2%/year
*[[Conduction|PR interval]]: 1° AVB &gt;50%; AVB 2%/year
*[[Heart axis|QRS axis]]: LAD
*[[Heart axis|QRS axis]]: LAD
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*Particularities: Absent sinus node in LAI; AV block with L-loop or AVCD
*Particularities: Absent sinus node in LAI; AV block with L-loop or AVCD


==Dextrocardia==
==Dextrocardia / Situs inversus==
*[[Rhythm]]: NSR; P-wave axis 105° to 165° with situs inversus
Information about [[w:Dextrocardia|Dextrocardia on Wikipedia (external link)]]
[[File:Puzzle_2007_12_426_fig1.jpg|thumb|300px|An example of dextrocardia]]
[[File:Situs_inversus.jpg|thumb|300px|Situs inversus]]
[[File:Situs_inversus_mirrored_lead_positioning.jpg|thumb|300px|Dextrocardia with mirrored lead positioning]]
*[[Rhythm]]: normal sinus rhythm, P-wave axis 105° to 165° with situs inversus
*[[Conduction|PR interval]]: Normal
*[[Conduction|PR interval]]: Normal
*[[Heart axis|QRS axis]]: RAD
*[[Heart axis|QRS axis]]: RAD
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*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: LVH: tall R V<sub>1</sub>–V<sub>2</sub>; RVH: deep Q, small R V<sub>1</sub> and tall R right lateral
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: LVH: tall R V<sub>1</sub>–V<sub>2</sub>; RVH: deep Q, small R V<sub>1</sub> and tall R right lateral
*Particularities: Situs solitus: normal P-wave axis and severe CHD
*Particularities: Situs solitus: normal P-wave axis and severe CHD
{{clr}}


==ALCAPA==
==ALCAPA==
 
Information about [[w:Anomalous_Left_Coronary_Artery_From_the_Pulmonary_Artery|ALCAPA on Wikipedia (external link)]]
*[[Rhythm]]: NSR
*[[Rhythm]]: normal sinus rhythm
*[[Conduction|PR interval]]: Normal
*[[Conduction|PR interval]]: Normal
*[[Heart axis|QRS axis]]: Possible LAD
*[[Heart axis|QRS axis]]: Possible LAD
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*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: Selective hypertrophy of posterobasal LV
*[[Chamber_Hypertrophy_and_Enlargment|Ventricular hypertrophy]]: Selective hypertrophy of posterobasal LV
*Particularities: Possible ischemia
*Particularities: Possible ischemia
==References==
<biblio>
#khairy pmid=18056539
</biblio>

Latest revision as of 18:55, 24 April 2013

Congenital Heart Disease can result in ECG changes, often related to atrial or ventricular overload and enlargement. Below a list of relatively common forms of congenital heart disease and their potential ECG changes. Adapted from Khairy et al.[1]

Secundum atrial septal defect

Information about Secundum atrial septal defec on Wikipedia (external link)

  • Rhythm: normal sinus rhythm, increased risk of AF with age
  • PR interval: first degree AV block in 6-19%
  • QRS axis: 0° to 180°; RAD; LAD in Holt-Oram or LAHB
  • QRS Configuration: rSr´ or rsR´ with RBBBi>RBBBc
  • Atrial Enlargement: RAE 35%
  • Ventricular hypertrophy: Uncommon
  • Particularities: "Crochetage" pattern

Ventricular Septal Defect

Information about Ventricular Septal Defect on Wikipedia (external link)

  • Rhythm: normal sinus rhythm, PVCs
  • PR interval: Normal or mild ↑; 1° AVB 10%
  • QRS axis: RAD with BVH; LAD 3% to 15%
  • QRS Configuration: Normal or rsr´; possible RBBB
  • Atrial Enlargement: Possible RAE±LAE
  • Ventricular hypertrophy: BVH 23% to 61%; RVH with Eisenmenger
  • Particularities: Katz-Wachtel phenomenon

AV canal defect

Information about AV canal defect on Wikipedia (external link)

  • Rhythm: normal sinus rhythm, PVCs 30%
  • PR interval: 1° AVB >50%
  • QRS axis: Moderate to extreme LAD; normal with atypical
  • QRS Configuration: rSr´ or rsR´
  • Atrial Enlargement: Possible LAE
  • Ventricular hypertrophy: Uncommon in partial; BVH in complete; RVH with Eisenmenger
  • Particularities: Inferoposteriorly displaced AVN

Patent ductus arteriosus

Information about Patent ductus arteriosus on Wikipedia (external link)

  • Rhythm: normal sinus rhythm, ↑ IART/AF with age
  • PR interval: ↑ PR 10% to 20%
  • QRS axis: Normal
  • QRS Configuration: Deep S V1, tall R V5 and V6
  • Atrial Enlargement: LAE with moderate PDA
  • Ventricular hypertrophy: Uncommon
  • Particularities: Often either clinically silent or Eisenmenger

Pulmonary stenosis

Information about Pulmonary stenosis on Wikipedia (external link)

  • Rhythm: normal sinus rhythm
  • PR interval: Normal
  • QRS axis: Normal if mild; RAD with moderate/severe
  • QRS Configuration: Normal; or rSr´; R´ increases with severity
  • Atrial Enlargement: Possible RAE
  • Ventricular hypertrophy: RVH; severity correlates with R:S in V1 and V6
  • Particularities: Axis deviation correlates with RVP

Aortic coarctation

Information about Aortic coarctation on Wikipedia (external link)

  • Rhythm: normal sinus rhythm
  • PR interval: Normal
  • QRS axis: Normal or LAD
  • QRS Configuration: Normal
  • Atrial Enlargement: Possible LAE
  • Ventricular hypertrophy: LVH, especially by voltage criteria
  • Particularities: Persistent RVH rare beyond infancy

Ebstein’s anomaly

ECG from a patient with Ebstein's anomaly showing huge P waves and low amplitude QRS waves. RBBB and T wave inversion are not present on this ECG.
ECG from a patient with Ebstein's anomaly

Information about Ebstein's anomaly on Wikipedia (external link)

  • Rhythm: normal sinus rhythm, possible EAR, SVT; AF/IART 40%
  • PR interval: 1° AVB common; short if WPW
  • QRS axis: Normal or LAD
  • QRS Configuration: Low-amplitude multiphasic atypical RBBB
  • Atrial Enlargement: RAE with Himalayan P waves
  • Ventricular hypertrophy: Diminutive RV
  • Particularities: Accessory pathway common; Q II, III, aVF, and V1–V4


Surgically repaired TOF

Information about Surgically repaired TOF on Wikipedia (external link)

  • Rhythm: normal sinus rhythm, PVCs; IART 10%; VT 12%
  • PR interval: Normal or mild ↑
  • QRS axis: Normal or RAD; LAD 5% to 10%
  • QRS Configuration: RBBB 90%
  • Atrial Enlargement: Peaked P waves; RAE possible
  • Ventricular hypertrophy: RVH possible if RVOT obstruction or PHT
  • Particularities: QRS duration±QTd predictive of VT/SCD

Congenitally corrected TGA

Information about Congenitally corrected TGA on Wikipedia (external link)

  • Rhythm: normal sinus rhythm
  • PR interval: 1° AVB >50%; AVB 2%/year
  • QRS axis: LAD
  • QRS Configuration: Absence septal q; Q in III, aVF, and right precordium
  • Atrial Enlargement: Not if no associated defects
  • Ventricular hypertrophy: Not if no associated defects
  • Particularities: Anterior AVN; positive T precordial; WPW with Ebstein’s

Complete TGA/intra-atrial baffle

  • Rhythm: Sinus brady 60%; EAR; junctional; IART 25%
  • PR interval: Normal
  • QRS axis: RAD
  • QRS Configuration: Absence of q, small r, deep S in left precordium
  • Atrial Enlargement: Possible RAE
  • Ventricular hypertrophy: RVH; diminutive LV
  • Particularities: Possible AVB if VSD or TV surgery

UVH with Fontan

  • Rhythm: Sinus brady 15%; EAR; junctional; IART >50%
  • PR interval: Normal in TA; 1° AVB in DILV
  • QRS axis: LAD in single RV, TA, single LV with noninverted outlet
  • QRS Configuration: Variable; ↑R and S amplitudes in limb and precordial leads
  • Atrial Enlargement: RAE in TA
  • Ventricular hypertrophy: RVH with single RV; possible LVH with single LV
  • Particularities: Absent sinus node in LAI; AV block with L-loop or AVCD

Dextrocardia / Situs inversus

Information about Dextrocardia on Wikipedia (external link)

An example of dextrocardia
Situs inversus
Dextrocardia with mirrored lead positioning
  • Rhythm: normal sinus rhythm, P-wave axis 105° to 165° with situs inversus
  • PR interval: Normal
  • QRS axis: RAD
  • QRS Configuration: Inverse depolarization and repolarization
  • Atrial Enlargement: Not with situs inversus
  • Ventricular hypertrophy: LVH: tall R V1–V2; RVH: deep Q, small R V1 and tall R right lateral
  • Particularities: Situs solitus: normal P-wave axis and severe CHD


ALCAPA

Information about ALCAPA on Wikipedia (external link)

  • Rhythm: normal sinus rhythm
  • PR interval: Normal
  • QRS axis: Possible LAD
  • QRS Configuration: Ant-lat Q waves; possible ant-sept Q waves
  • Atrial Enlargement: Possible LAE
  • Ventricular hypertrophy: Selective hypertrophy of posterobasal LV
  • Particularities: Possible ischemia

References

  1. Khairy P and Marelli AJ. Clinical use of electrocardiography in adults with congenital heart disease. Circulation. 2007 Dec 4;116(23):2734-46. DOI:10.1161/CIRCULATIONAHA.107.691568 | PubMed ID:18056539 | HubMed [khairy]
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