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