11
R. TANDON
22
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
33
Investigations are complimentary to each other in helping reach an accurate clinical diagnosis.
44
ECG is the quickest, safest, least expensive and most widely available cardiac investigative tool.
55
Electrocardiogram : Utility Identify cardiac malposition. Atrial and ventricular hypertrophy
- specific dx.- assess severity
Pericard. and myocard. disease. Electrolyte imbalance. Atriovent. & intravent conduction
abn. Arrhythmias.
66
77
In congenital heart disease interpretation of the ECG is useful only on the patient’s bedside.
88
CONGENITAL HEART DISEASECONGENITAL HEART DISEASE
ECG Crucial data Age Cyanotic or acyanotic Heart size – x-ray
99
Electrocardiogram
At Birth : RAD (+90 to +120) RVH
At 2 to 5 years :-Normal axis (+30 to +75)Normal LV dominanceTransitional period (Unstable ECG)
1010
CONGENITAL HEART DISEASE
CLASSIFICATION
L R shunts Obstr. lesions Cyanotic pts
• Atrial level Right sided With PS• Vent. Level Left sided With PAH• PA level
1111
CONGENITAL HEART DISEASE
CYANOTIC : Subgroups PS, no VSD, R to L at atrial level PS with VSD (TOF physiology). pulm flow (Transposition physiol.) PA pr , pulm. flow (Eisenmenger
physiol). Pulm. ven. obst. PA pr. normal, No PS, No PAH.
1212
CONGENITAL HEART DISEASE
L to R Shunts : Atrial levelQRS axis-30 to +150 Atrial septal
defect 2°QRS axis-15 to -120 Atrial septal defect
1°Atrial septal defect 2° - rsR1 – V1 - 95%RVH PAHAtrial septal defect 1° - right, left, right
+ left, V.H.
1313
1414
1515
CONGENITAL HEART DISEASE
L to R Shunts : Vent. & PA levelNormal axis.L.V. dominance or LVH.RVH PS or PAH.PDA : Left ventricular hypertrophy
with ST and T changes of ischaemia indicates associated Aortic stenosis or LVEFE.
1616
1717
CONGENITAL HEART DISEASE
Obstructive lesions :-RVH : Right sided lesion (PS)
(Except in newborns and neonates).Left ventricular hypertrophy – left
sided lesion (Aortic stenosis, C of A0)ST and T changes in Coarct. of A0
indicates associated Aortic stenosis or LVEFE.
1818
CONGENITAL HEART DISEASECONGENITAL HEART DISEASE
Obstructive lesions :-As a rule severity of RVH or LVH is
consistent with the severity of obstruction.
Presence of ST and T changes.Severe obstr.Myocardial dis.
1919
2020
2121
CONGENITAL HEART DISEASE
Cyanotic : QP, No VSD, CE+ (R L at atrial level)
Pure PS - SevereEbsteins anomaly.
2222
2323
2424
CONGENITAL HEART DISEASE
Cyanotic : TOF physiology (VSD + PS)
Clinical : No CE, S1 normal.S2 single, eject syst.
murmur.X-ray : No cardiomegaly.
Ischaemic lungs. Ao large.
2525
CONGENITAL HEART DISEASE
RAD RVH RAD LVH LAD LVH LAD RVH
TOF RV TA AVC
DORV SV SV SV
TGASV
DORV (Small VSD)
DORV (Rare)
DORV(Rare)
Cyanotic : TOF physiology
2626
2727
2828
2929
CONGENITAL HEART DISEASE
Cyanotic : TOF physiologyLAD or RADEquiphasic complexes across.precordium, q may be absent. Single ventricle.
3030
3131
CONGENITAL HEART DISEASE
RAD RVH
RAD LVH
LAD LVH LAD RVH
TGA RV TA SV
TAPVC SV SV AVC
DORVPTA
- RVAVC
-
SV - - -
Cyanotic : TGA physiologyCE + Congestive cardiac failure + Age - NB
3232
3333
3434
CONGENITAL HEART DISEASECONGENITAL HEART DISEASE
Cyanotic Patients : Eisenmenger Phys.
RAD RVH RAD LVH LAD LVH LAD RVH
VSD, PDA, APW
RV TA AVC
TGA Physiol.
SV SV SV
ASD 2° - - -
3535
3636
3737
CONGENITAL HEART DISEASECONGENITAL HEART DISEASE
Cyanotic Patients : Pulm. Ven. Obstru.
‘P’ Pulm, RAD, RVH.Hypoplastic left heartTAPVC with PV obstru.
(Xray – Diagnostic)
3838
3939
CONGENITAL HEART DISEASECONGENITAL HEART DISEASE
Cyanotic : Miscellaneous(No PS, normal PA pr).RAD RVH - TA PVC.LAD RVH - Single atriumNormal ECG - SVC to LA.
Pulm. AV fistula.
4040
SPOT DIAGNOSIS BY ECG
ALCAPA Ebstein’s anomaly Ventricular inversion (l-loop) Situs inversus Hypertrophic cardiomyopathy
4141
4242
4343
4444
4545
4646
Arrhythmias and conduction defects suggest specific congenital cardiac anomalies
4747
SSS ASD in Holt Oram synd. Sinus venosus ASD. AV canal defects Ebstein’s anomaly. Asplenia, polysplenia synd.
4848
4949
Narrow QRS tachycardia
Ebstein’s disease. Cong. CTGA LV – RA shunt AV canal defects Older pts of TA and ASD 2°.
5050
Wide QRS tachycardia
ALCAPA Coron. arterio-ven. fistula Arrhythmogenic RV dysplasia.
5151
Atrioventricular conduction defects and pre-excitation syndrome Ebstein’s disease. Cong. CTGA
5252
Age : 3 yrs, acyanotic.
Dx. : PDA, No PAHShunt 2:1.
X-ray : No CE, Ao+, MPA +Vasc : N to +.
5353
5454
Age : 2 m, cyanotic
Dx. : Transposition physiology
X-ray : CE ++, Vasc. ++.
5555
5656
Age : 2 yrs, cyanotic
Dx. : Fallots’ physiology
X-ray : No CE, Vasc. , Ao+.
5757
5858
Age : 12 yrs, cyanotic
Dx. : Eisenmenger physiology
X-ray: CE +, Vasc : Prominent hilar vasc.,
Ischaemic periphery.
5959
6060
CONGENITAL HEART DISEASECONGENITAL HEART DISEASE
Electrocardiogram provides diagnostic help only on the bedside of the patient from whom the ECG has been taken.
6161