ECG in Congenital Heart Disease

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Secundum atrial septal defect

  • 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

AV canal defect

Patent ductus arteriosus

Pulmonary stenosis

Aortic coarctation

Ebstein’s anomaly

Surgically repaired TOF

  • Rhythm: NSR; 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

  • Rhythm: NSR
  • 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

  • Rhythm: NSR; 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

  • Rhythm: NSR
  • 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
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