R TANDON 1 ECG accurate physical examination and
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R. TANDON 1
ECG, accurate physical examination and radiology form the tripod on which rests the clinical diagnosis in Ped. Card. Omission of, unfamiliarity with or misinterpretation of any of these three tools spells disaster. Alexander S. Nadas 2
Investigations are complimentary to each other in helping reach an accurate clinical diagnosis. 3
ECG is the quickest, safest, least expensive and most widely available cardiac investigative tool. 4
Electrocardiogram : Utility l Identify cardiac malposition. l Atrial and ventricular hypertrophy - specific dx. - assess severity l Pericard. and myocard. disease. l Electrolyte imbalance. l Atriovent. & intravent conduction abn. l Arrhythmias. 5
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In congenital heart disease interpretation of the ECG is useful only on the patient’s bedside. 7
CONGENITAL HEART DISEASE ECG Crucial data l Age l Cyanotic or acyanotic l Heart size – x-ray 8
Electrocardiogram At Birth : RAD (+90 to +120) RVH At 2 to 5 years : Normal axis (+30 to +75) Normal LV dominance Transitional period (Unstable ECG) 9
CONGENITAL HEART DISEASE CLASSIFICATION L R shunts Obstr. lesions Cyanotic pts Atrial level • Vent. Level • PA level • Right sided Left sided With PS With PAH 10
CONGENITAL HEART DISEASE CYANOTIC : Subgroups l PS, no VSD, R to L at atrial level l PS with VSD (TOF physiology). l pulm flow (Transposition physiol. ) l PA pr , pulm. flow (Eisenmenger physiol). l Pulm. ven. obst. l PA pr. normal, No PS, No PAH. 11
CONGENITAL HEART DISEASE L to R Shunts : Atrial level QRS axis-30 to +150 Atrial septal defect 2° l QRS axis-15 to -120 Atrial septal defect 1° l Atrial septal defect 2° - rs. R 1 – V 1 - 95% l RVH PAH l Atrial septal defect 1° - right, left, right + left, V. H. l 12
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CONGENITAL HEART DISEASE L to R Shunts : Vent. & PA level l Normal axis. l L. V. dominance or LVH. l RVH PS or PAH. l PDA : Left ventricular hypertrophy with ST and T changes of ischaemia indicates associated Aortic stenosis or LVEFE. 15
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CONGENITAL HEART DISEASE Obstructive lesions : l RVH : Right sided lesion (PS) (Except in newborns and neonates). l Left ventricular hypertrophy – left sided lesion (Aortic stenosis, C of A 0) l ST and T changes in Coarct. of A 0 indicates associated Aortic stenosis or LVEFE. 17
CONGENITAL HEART DISEASE Obstructive lesions : l As a rule severity of RVH or LVH is consistent with the severity of obstruction. l Presence of ST and T changes. l Severe obstr. l Myocardial dis. 18
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CONGENITAL HEART DISEASE Cyanotic : QP, No VSD, CE+ (R L at atrial level) l. Pure PS - Severe l. Ebsteins anomaly. 21
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CONGENITAL HEART DISEASE Cyanotic : TOF physiology (VSD + PS) Clinical : No CE, S 1 normal. S 2 single, eject syst. murmur. X-ray : No cardiomegaly. Ischaemic lungs. Ao large. 24
CONGENITAL HEART DISEASE Cyanotic : TOF physiology RAD RVH TOF RAD LVH RV LAD LVH LAD RVH TA AVC SV SV DORV SV TGA SV DORV (Small VSD) (Rare) DORV (Rare) 25
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CONGENITAL HEART DISEASE Cyanotic : TOF physiology LAD or RAD Equiphasic complexes across. precordium, q may be absent. Single ventricle. 29
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CONGENITAL HEART DISEASE Cyanotic : TGA physiology CE + Congestive cardiac failure + Age - NB RAD RVH RAD LVH LAD LVH TGA RV LAD RVH TA SV TAPVC SV SV AVC DORV PTA SV - RV AVC - - - 31
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CONGENITAL HEART DISEASE Cyanotic Patients : Eisenmenger Phys. RAD RVH VSD, PDA, APW RAD LVH RV LAD LVH LAD RVH TA AVC TGA Physiol. SV SV SV ASD 2° - - 34
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CONGENITAL HEART DISEASE Cyanotic Patients : Pulm. Ven. Obstru. ‘P’ Pulm, RAD, RVH. l Hypoplastic left heart l TAPVC with PV obstru. (Xray – Diagnostic) 37
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CONGENITAL HEART DISEASE Cyanotic : Miscellaneous (No PS, normal PA RAD RVH LAD RVH Normal ECG - pr). TA PVC. Single atrium SVC to LA. Pulm. AV fistula. 39
SPOT DIAGNOSIS BY ECG l l l ALCAPA Ebstein’s anomaly Ventricular inversion (l-loop) Situs inversus Hypertrophic cardiomyopathy 40
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Arrhythmias and conduction defects suggest specific congenital cardiac anomalies 46
SSS l ASD in Holt Oram synd. l Sinus venosus ASD. l AV canal defects l Ebstein’s anomaly. l Asplenia, polysplenia synd. 47
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Narrow QRS tachycardia l l l Ebstein’s disease. Cong. CTGA LV – RA shunt AV canal defects Older pts of TA and ASD 2°. 49
Wide QRS tachycardia ALCAPA l Coron. arterio-ven. fistula l Arrhythmogenic RV dysplasia. l 50
Atrioventricular conduction defects and pre-excitation syndrome l Ebstein’s disease. l Cong. CTGA 51
Age : 3 yrs, acyanotic. Dx. : PDA, No PAH Shunt 2: 1. X-ray : No CE, Ao+, MPA + Vasc : N to +. 52
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Age : 2 m, cyanotic Dx. : Transposition physiology X-ray : CE ++, Vasc. ++. 54
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Age : 2 yrs, cyanotic Dx. : Fallots’ physiology X-ray : No CE, Vasc. , Ao+. 56
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Age : 12 yrs, cyanotic Dx. : Eisenmenger physiology X-ray : hilar periphery. CE +, Vasc : Prominent vasc. , Ischaemic 58
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CONGENITAL HEART DISEASE Electrocardiogram provides diagnostic help only on the bedside of the patient from whom the ECG has been taken. 60
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