ECG Rounds:

1. ECG Rounds: Dr. Dave Dyck R3 April 3, 2003

2. Case 1: • 2 week infant with tachypnea (RR=60-70), tachycardia (170) and “dusky” in appearance.

4. Cardiologists Interpretation: • Sinus rhythm. Heart Rate 160. • QRS axis 90. PR 130ms. QRS 50ms. QT/QTc 280/450 • Right atrial hypertrophy • Right ventricular hypertrophy • LV strain/ischaemia

6. Of Note: • The T wave changes are the most significant features of this ECG. • An upright T wave in V1 in a 2 week old infant is abnormal and may signify RV systolic hypertension. • Inverted T waves in V5-6 are evidence of LV strain which may cause reciprocally upright T waves in the right chest leads. • (TGA/VSD/PA)

7. Case 2: • 13m female with failure to thrive and worsening tachypnea sent to ER by GP • HR=125 RR=42 O2sat=94%

8. ECG:

9. Cardiologist’s Interpretation: • Sinus rhythm. Rate 124. QRS axis +150.PR 150ms. QRS 60ms. QT/QTc 240/340Bi-atrial hypertrophy, left >rightRight axis deviationRight ventricular hypertrophy • (upright T waves in V1= abnormal)

10. ECG:

11. Of Note: • This young child was born with a dysmorphic mitral valve which has resulted in both mitral stenosis and incompetance. • The right sided hypertrophy is a result of pulmonary hypertension caused by her elevated left heart pressures.

12. Pediatric ECGs • Often 13 lead ECGs done (V3R or V4R) for the evaluation of RVH in children

13. V1 inverted Ts: • 1st day = RAD, large R waves + upright T waves in right precordial leads (V3R, V1) •  by 48 hrs: inverted T waves in V1, V3R • Upright Ts > 1 wk  pathologic (RVH or strain) • Should never be upright before age 6 and often into adolescence

14. Axis: • Newborn Axis: usually +110 - +180 • V1, V3R have R>S wave usually and often for months/years (up to 8 yrs) • Over the years, the QRS axis gradually shifts leftward and right ventricular forces slowly regress • If it looks like a normal adult ECG early on think LVH

15. Pediatric Heart Chamber Hypertrophy: • Right Atrial Enlargement (RAE): • P wave > 2 mm tall in infants and small children and > 3 mm tall in older children • P waves best seen in inferior (I,II & aVF) and the right chest leads (V3R, V1 & V2)

16. RAE:

17. Left Atrial Enlargement: • Wide P waves > 2 mm wide (.08s) in infants and small children and more than 3 mm wide (.12s) in larger children • Best seen in inferolateral leads

18. LAE:

19. P wave morphology in AE:

20. Right Ventricular Hypertrophy: • R in V1 >95% of normal + S in V6 deeper than 95% of normal

22. RVH #2 • rsR’ in V1 & V2 without a widened QRS duration as in RBBB (note= 2nd R is larger)

23. RVH #3 • qR in V1 and V2

24. RVH #4 • Pure R in V1 & V2 +/- strain changes

25. Left Ventricular Hypertrophy (LVH): • S in V1 deeper than 95% of normal and R in V6 taller than 95% of normal

26. Summary: • From 5 days to age 6, upright T waves in V1 are abnormal. • RAD (& V3R, V1 R>S) is prominent early and is normal • RVH in kids • 1. R in V1>95% of normal and S in V6 deeper than 95% • 2. RsR’ in V1(2) without widened QRS • 3. qR in V1(2) • 4. pure R in V1(2) +/- strain • Ventricular hypertrophy in children is based on comparison to statistical norms