ECG in Congenital Heart Disease

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.khairy

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

<biblio>

1. khairy pmid=18056539

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