1. ECG Underwriting Puzzler Presented by: Bill Rooney, M.D.

2. Select “From the beginning” Obtaining Best Results from this presentation 2 For best results—please do the following: Select “Slide Show” from the menu option on top For best results—please do the following: Select “Slide Show” from the menu option on top Slowly click through the presentation Have fun!---Good luck Slowly click through the presentation Have fun!---Good luck

3. ECG Puzzler 3 Here is an ECG on a 31 y/o male who is applying for life insurance. Application mentions having a “Mustard Procedure” as a child. How would you interpret this ECG? 3

4. ECG Puzzler After inspecting for technical issues let’s examine the ECG using our usual routine: 1) Rhythm 2) Axis 3) Intervals 4) Q waves 5) Hypertrophy 6) ST/T waves After inspecting for technical issues let’s examine the ECG using our usual routine: 1) Rhythm 2) Axis 3) Intervals 4) Q waves 5) Hypertrophy 6) ST/T waves Normal rhythm? Yes, normal sinus rhythm Normal Axis? No! Right Axis Deviation (RAD) present. ~ +145 o Normal Intervals? No. QRS complex ~0.10 sec. ICRBBB Significant Q waves? No. Hypertrophy? Yes, Right Ventricular Hypertrophy (RVH) present ST/T wave abnormalities? Technically, any issues? No. The copy could be of better quality but…. 4 Yes, RVH strain pattern with ST depression/T wave inversion in the right precordial leads (V1-3)

5. ECG Puzzler 5 RVH should be suspected when there is: R in V1 >6 mmR in V1 and S in V5 or V6 >10.5 mm Right Axis Deviation (RAD)R/S ratio in V1 >1 Right atrial hypertrophyIncomplete RBBB present RVH should be suspected when there is: R in V1 >6 mmR in V1 and S in V5 or V6 >10.5 mm Right Axis Deviation (RAD)R/S ratio in V1 >1 Right atrial hypertrophyIncomplete RBBB present So, what is the Mustard procedure? How does it compare to other surgical procedures? The Mustard Procedure is one of the surgical procedures performed shortly after birth when the congenital heart defect known as transposition of the great arteries occurs. Let’s go to the next slide and review that condition.

6. Transposition of the great arteries is a congenital heart defect. The aorta arises from the right ventricle. The pulmonary artery arises from the left ventricle. Surgery is required for survival Transposition of the great arteries is a congenital heart defect. The aorta arises from the right ventricle. The pulmonary artery arises from the left ventricle. Surgery is required for survival There are two commonly performed operations for this condition (Sometimes there are other associated heart defects requiring other procedures but we won’t get into that today) Arterial switch procedure Atrial switch procedures (Mustard and Senning procedure) There are two commonly performed operations for this condition (Sometimes there are other associated heart defects requiring other procedures but we won’t get into that today) Arterial switch procedure Atrial switch procedures (Mustard and Senning procedure) 6 D-Transposition of the Great Arteries 6

7. Atrial switch procedure 7 The Mustard procedure is what this individual had performed. In this procedure an intra-Atrial tunnel is surgically formed. Long term risk of this procedure include: Right ventricular failure Arrhythmias Tunnel (baffle) related complications such as obstruction at the right atrial- superior vena cava junction Long term risk of this procedure include: Right ventricular failure Arrhythmias Tunnel (baffle) related complications such as obstruction at the right atrial- superior vena cava junction The result of this procedure is that the right ventricle pumps blood to the systemic circulation instead of the typical pumping of blood to the lungs. This can eventually cause significant right ventricular hypertrophy. Before After http://www.yorksandhumberhearts.nhs.uk/templates/page.aspx?id=415

8. Arterial switch procedure 8 The arterial switch procedure is what is more commonly used now. The aorta and the pulmonary artery are transected and then translocated to the opposite root. This creates ventriculo-arterial concordance (aorta-left ventricle; pulmonary artery-right ventricle) This procedure requires dissection and then re- implantation of the coronary arteries. The procedure is usually done within the first 2 weeks of life. Suture lines

9. 9 Long term complications of the arterial switch procedure include: Pulmonary artery stenosis Coronary artery insufficiency Neo-aortic root dilation Neo-aortic regurgitation However, this procedure can change a uniformly fatal disorder without some kind of repair to a long term fairly favorable outcome! Long term complications of the arterial switch procedure include: Pulmonary artery stenosis Coronary artery insufficiency Neo-aortic root dilation Neo-aortic regurgitation However, this procedure can change a uniformly fatal disorder without some kind of repair to a long term fairly favorable outcome! That concludes this issue’s ECG Underwriting Puzzler!! Contact me if you have any questions!! Back to this specific ECG. The ECG showing RVH is a clue that there appears to be significant mortality concerns in this individual. Interesting ECG indeed!!