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ECG Corner
Acknowledgements
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Over the past 25 years I have interpreted a huge number of electrocardiograms for patients I have been privileged to treat. I have archived a number of these tracings and will use this platform to share some of them with young doctors.
I would like to thank my junior colleagues and medical students who have spent many hours with me in cardiology clinics, ward rounds and tutorials. Your searching questions have inspired me to compile this collection.
I would also like to acknowledge my friend and colleague – Professor Charles Gaymes -Pediatric Electrophysiologist (Mississippi- USA) for his unwavering enthusiasm in providing prompt second opinions on challenging electrocardiograms.
Electrocardiogram #8
Ten month old male infant with complete Transposition of the great arteries
Note:
Right atrial enlargement (Tall P waves in Leads 11, 111, and aVF)
Right Ventricular Hypertrophy (Right Axis Deviation, Deep S in V6 and upright T in V1).
Right Ventricular Hypertrophy is due to systemic overloading of the right ventricle, as this ventricle is now connected to high systemic pressures in the Aorta. The left ventricular forces are decreased as the left ventricle is not the systemic ventricle and is pumping against the lower pressures in the pulmonary circuit. The left ventricle mass therefore melts quite rapidly within the first month of birth. It is therefore critical that the arterial switch operation for correction of this condition be done as soon after birth as possible before the left ventricular mass diminishes and can no longer take over the role as the systemic ventricle
Electrocardiogram #7
Nine year old boy with prolonged PR interval (First degree atrioventricular AV block)
Note:
Prolonged PR interval also known as first degree atrioventricular (AV) block.
This may be a normal variant in children
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It is a minor criterion in the diagnosis of Acute Rheumatic fever
First degree atrioventricular block occurs when conduction through the atrioventricular node is slowed. This results in longer time for the electrical activity to travel from the sinoatrial node through the AV node to the ventricles. This is indicated on the electrocardiogram as an increase in the PR interval
Electrocardiogram # 6
Four year old boy with Tetralogy of Fallot
​​Note:
Right Ventricular Hypertrophy – Right axis deviation (QRS negative in lead 1 and positive in AVF), Deep S wave in V6 and upright T in V1
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Tetralogy of Fallot as per renowned Professor of paediatric cardiac morphology Robert Anderson should really be named “Monology of Fallot”. The single significant abnormality present is antereo and cephalad deviation of the infundibular septum leading to right ventricular out flow obstruction. The overriding aorta, ventricular septal defect (VSD) occur as a result of this deviation and of course right ventricular hypertrophy the consequence of the right ventricular outflow obstruction. Commonly there is associated pulmonary valve and artery stenosis.
The electrocardiogram finding associated with this condition reflects this principle and tells the story. Right ventricular outflow obstruction causing pressure load on the right ventricle.
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Although there is a large VSD, both ventricles are at the same pressure so there is no left ventricular overload (LVH) from VSD flow. The Right ventricular pressure is never super high as the VSD acts as a pop off valve for the right ventricle. So clinically heart failure is not a feature of this condition.
