1 R. TANDON

2 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

3 Investigations are complimentary to each other in helping reach an accurate clinical diagnosis.

4 ECG is the quickest, safest, least expensive and most widely available cardiac investigative tool.

5 Electrocardiogram : Utility Identify cardiac malposition. Atrial and ventricular hypertrophy - specific dx. - assess severity Pericard. and myocard. disease. Electrolyte imbalance. Atriovent. & intravent conduction abn. Arrhythmias.

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7 In congenital heart disease interpretation of the ECG is useful only on the patient’s bedside.

8 CONGENITAL HEART DISEASE ECG Crucial data Age Cyanotic or acyanotic Heart size – x-ray

9 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)

10 CONGENITAL HEART DISEASE CLASSIFICATION L  R shuntsObstr. lesionsCyanotic pts Atrial levelRight sidedWith PS Vent. LevelLeft sidedWith PAH PA level

11 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.

12 CONGENITAL HEART DISEASE L to R Shunts : Atrial level QRS 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  PAH Atrial septal defect 1° - right, left, right + left, V.H.

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15 CONGENITAL HEART DISEASE L to R Shunts : Vent. & PA level Normal 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.

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17 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.

18 CONGENITAL 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.

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21 CONGENITAL HEART DISEASE Cyanotic :  QP, No VSD, CE+ (R  L at atrial level) Pure PS - Severe Ebsteins anomaly.

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24 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.

25 CONGENITAL HEART DISEASE RAD RVHRAD LVHLAD LVHLAD RVH TOF  RV TAAVC DORVSV TGA SV DORV (Small VSD) DORV (Rare) DORV (Rare) Cyanotic : TOF physiology

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29 CONGENITAL HEART DISEASE Cyanotic : TOF physiology LAD or RAD Equiphasic complexes across. precordium, q may be absent. Single ventricle.

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31 CONGENITAL HEART DISEASE RAD RVHRAD LVHLAD LVHLAD RVH TGA  RV TASV TAPVCSV AVC DORV PTA -  RV AVC - SV--- Cyanotic : TGA physiology CE + Congestive cardiac failure + Age - NB

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34 CONGENITAL HEART DISEASE Cyanotic Patients : Eisenmenger Phys. RAD RVHRAD LVHLAD LVHLAD RVH VSD, PDA, APW  RV TAAVC TGA Physiol. SV ASD 2°---

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37 CONGENITAL HEART DISEASE Cyanotic Patients : Pulm. Ven. Obstru. ‘P’ Pulm, RAD, RVH. Hypoplastic left heart TAPVC with PV obstru. (Xray – Diagnostic)

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39 CONGENITAL HEART DISEASE Cyanotic : Miscellaneous (No PS, normal PA pr). RAD RVH-TA PVC. LAD RVH-Single atrium Normal ECG-SVC to LA. Pulm. AV fistula.

40 SPOT DIAGNOSIS BY ECG ALCAPA Ebstein’s anomaly Ventricular inversion (l-loop) Situs inversus Hypertrophic cardiomyopathy

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46 Arrhythmias and conduction defects suggest specific congenital cardiac anomalies

47 SSS ASD in Holt Oram synd. Sinus venosus ASD. AV canal defects Ebstein’s anomaly. Asplenia, polysplenia synd.

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49 Narrow QRS tachycardia Ebstein’s disease. Cong. CTGA LV – RA shunt AV canal defects Older pts of TA and ASD 2°.

50 Wide QRS tachycardia ALCAPA Coron. arterio-ven. fistula Arrhythmogenic RV dysplasia.

51 Atrioventricular conduction defects and pre-excitation syndrome Ebstein’s disease. Cong. CTGA

52 Age:3 yrs, acyanotic. Dx.:PDA, No PAH Shunt  2:1. X-ray:No CE, Ao+, MPA + Vasc : N to +.

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54 Age:2 m, cyanotic Dx.:Transposition physiology X-ray:CE ++, Vasc. ++.

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56 Age:2 yrs, cyanotic Dx.:Fallots’ physiology X-ray:No CE, Vasc. , Ao+.

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58 Age:12 yrs, cyanotic Dx.:Eisenmenger physiology X-ray:CE +, Vasc : Prominent hilar vasc., Ischaemic periphery.

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60 CONGENITAL HEART DISEASE Electrocardiogram provides diagnostic help only on the bedside of the patient from whom the ECG has been taken.

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