ECG IN PEDIATRICS

1. ECG IN CHILDREN
MURTAZA KAMAL
FOR
PG FORUM
OCT/ 06/ 2018, HYDERABAD
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2. SCOPE OF THIS TALK
Pediatric EGG:
Differences from adults
Developmental changes with age
ECG in some congenital heart diseases
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3. MIND THESE POINTS…
• Children are not small adults
• Small in size, small chest size
• Normal criteria which are for adults Cannot be followed in kids
• Z Scores
3

4. WHO AM I??
• Dutch physiologist
• Nobel Prize in Physiology: 1924
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5. LANDMARK IN ECG DEVELOPMENT
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6. ECG STANDARDS FOR KIDS…
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7. DEVELOPMENTAL CHANGES WITH AGE
• Decrease in HR
• Increase in P-wave duration, PR interval, QRS duration
• QRS Voltage: Low during 1st several months
• Mean QRS axis in frontal plane: Moves from right to left
• Increase in PR interval+ QRS duration: Changes in size of heart /AV node
7

8. VENTRICULAR DOMINANCE
• Newborn: QRS potentials result from RVRV dominance
• Transition of ECG from RV dominance at birth to pattern of LV: Lags behind
hemodynamic changes
• Loss of RV dominance:
• Starts at 1 month of age
• LV dominance is well established by 1 year
8

9. VENTRICULAR DOMINANCE
• 1st several weeks:
• Tall R+ small S in right and anterior precordium: V3R, V4R, and V1
• Deep S+ small R in left precordium: V6 and V7
• Corresponds to clockwise vector loop in horizontal plane
• 2 months of age:
• Precordial leads progress to more adult pattern
• Deeper S waves in right and taller R waves in left leads
• Counterclockwise vector loop in horizontal plane
• 1 year: Precordial R wave progression similar to adults
9

10. T WAVE CHANGES
• Rapid changes of RV pressure after birth: Great effect on T wave
• 1st minutes after birth, T-wave vector: Anterior and to left i.e upright in V1+ V6
• May swing rightward in next several hours: Flattening/ inversion of T in left
lateral leads
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11. T WAVE CHANGES
• Next 7 days:
• T-wave vector moves posterior+ leftward
• Inverted T in V1+ upright T in V6
• After 7- 8 years: Becomes upright again in V1
• May remain inverted throughout adolescence: Juvenile T-wave pattern
11

12. LETS THINK…
• Neonates with CCHD have RAD+ RVH
• RAD+ RV dominance  Rule in normal infants too
• SO, RVH WILL BE SUGGESTED BY??
• AXIS> +120 degrees
• Upright T in V1/ V3R
• Monophasic tall R in V1/ V3R
• RV strain pattern
12

13. PRE-TERM INFANTS: HOW R THEY DIFFERENT??
• Notable for its shorter QRS duration, PR interval and QT interval
• Less RV dominance at birth than ECG of full-term infant
• Precordial voltages: Lower in 1-year-old infant who was premature
• Intrinsic myocardial differences of premature or to altered cardiac–torso
geometry: Unknown
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14. ECG IN DIFFERENT
CONGENITAL CARDIAC
CONDITIONS
14

15. LETS TRY THIS (1)…
• 2Y old, Girl with cyanosis
• DIAGNOSIS…CLUES:
• RAD, CW-LOOP, SUDDEN
TRANSITION FRON V1
V2
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16. FALLOT’S TETROLOGY
• P waves: Often normal/ May be peaked but not tall
• P wave duration: Short Under filled and relatively
small LA writes terminal force
• PR interval: Normal Conduction system normal
• QRS complex: RAD, Normal duration
• LAD + Counterclockwise depolarization in Fallot’s
tetralogy??
 TOF WITH AVCD 16

17. FALLOT’S TETROLOGY
• RV hypertrophy: Tall monophasic R wave confined to V1
• Abrupt change to an rS pattern in V2: Sudden transition
• Depth of Q waves+ amplitude of R waves in V5-6: Indicate LV filling
• Reduced PBF+ underfilled LV  rS patterns in V2-6
• A balanced shunt accompanied by small q waves+ well-developed R waves in
V5-6
• Inverted right precordial T waves: Seldom occur, WHY??
• RVSP seldom exceeds systemic pressure 17

18. TOF WITH PA
• PA+ Abundant collateral arterial
circulation P waves broad and bifid
• Q waves with well-developed R waves
Leads V5-6
• ST segment+ T wave abnormalities
May be found in midprecordial leads
18

19. PROBLEM WITH DCRV…
• Increase in RV pressure+ mass
confined to hypertensive
proximal compartment
• Hence, precordial leads display
normal QRS progression
from V1-6
ANY CLUE?? 19

20. SO…
• Upright T wave in V3R
may be the only ECG
sign of right ventricular
hypertrophy
20

21. TOF WITH ABSCENT PULMONARY VALVE
• Tall monophasic R wave in
lead V1 extends to adjacent
precordial leads, in contrast
to Fallot’s Tetralogy
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22. LETS TRY THIS (2)…
• 8 months old, boy,
cyanosis and
respiratory distress
• DIAGNOSIS.. CLUES…
• LAD, CC-W LOOP,
PROLONGED PR
22

23. DORV, SUB AORTIC VSD AND NO PS
• P waves: Peaked
• Peaked RA P waves associated with bifid broad LA P waves when PBF increases
• PR prolongation: Due to prolonged course of AV bundle
• LAD with counterclockwise depolarization
• Elevated PVR associated with RAD and pure RVH
• LV volume overload indicated by large RS complexes in midprecordial leads and
tall R waves in left precordial leads
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24. LETS TRY THIS (3)…
• 2 y, girl
• Cyanosis, No RD
• DIAGNOSIS… CLUE…
• TOF PHYSIOLOGY, RAD,
CC-W LOOP
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25. DORV, SUB AORTIC VSD WITH PS
MILD STENOSIS: SIMILAR TO NO PS
• Peaked and broad P waves
• Prolonged PR interval
• Left axis deviation
• As stenosis increases QRS axis
becomes vertical or rightward
• Distinctive feature: Persistence of
counterclockwise initial forces
• Terminal forces are deep and prolonged
with broad slurred S waves in leads 1,
aVL, and V5-6 and a broad R wave in
lead aVR
• DORV, PA: ECG similar to TOF with PA
25

26. TAUSSIG-BING ANOMALY
• PR interval prolongation:
Less frequent than DORV,
subaortic VSD
• Biatrial P wave
abnormalities: RV failure
• QRS axis: Vertical or
rightward with clockwise
depolarization
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27. TAUSSIG-BING ANOMALY
• RV hypertrophy:
• Tall R waves in V1 and aVR and
• Deep S waves in left precordial leads
• Volume overload of LV: Well developed R waves in V5-6
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28. TGA
• Tall peaked right atrial P
waves: Mean RA pressure
increased (systemic
circulation)
• LA P wave abnormalities:
Reserved for patients with
large ASD+ increased PBF
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29. TGA CONT…
QRS axis :
• RAD: Most striking when ASD occurs
with increased PBF, normal PA pressure
• RAD occurs when LV volume overload
is curtailed by pulmonary vascular
disease or PS
• BVH: Nonrestrictive VSD with low PVR+
both volume+ pressure overload of LV
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30. TGA CONT…
• Right precordial T waves seldom
deeply inverted, even the systemic
RV is volume-overloaded
• Not only positive but tend to be
distinctly taller than left precordial
T waves
30

31. LETS TRY THIS (4)…
• 24 year old, male
• Acyanotic, no respiratory
distress
• Presented with history of
palpitations
• DIAGNOSIS…CLUES…
• Abscent q in lt prec l
• QS pattern in rt prec leads
31

32. CC-TGA
Pathophysiology:
• Atrial septum is malaligned with inlet ventricular septum
• Anomalous anterior AV node instead of regular AV node makes contact with
right and left bundle branches
• Long penetrating A-V bundle
• Conduction fibres replaced with fibrous tissue Responsible for AV block
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33. CC-TGA CONT…
Scalar ECG exhibits:
Disturbances in conduction and rhythm
QRS and T wave patterns that reflect ventricular inversion
AV Blocks:
• Varying degrees of AV block in how much percent of people??
• 75%
• Overall incidence rate of CHB??
• 30%
• Degree of block varies from time to time in same patient
33

34. CC-TGA CONT…
• Absent Q waves in left sided
precordial leads
• QS pattern in Rt sided leads
• Marked LAD
• RAD in case of LtRt shunts and PS
• Lt Ebsteins AV valve anamoly
associated with accessory pathways
• Lt AVVR associated with P wave
changes and AF
34

35. LETS TRY THIS (5)…
• 2 months old child
• Cyanosis
• No RD
• Left apex
• DIAGNOSIS…CLUE…
• LAD, LVH
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36. TRICUSPID ATRESIA WITH NRGA
• Tall peaked RA P waves
• LA seldom represented, even it
receives entire return from
both systemic+ pulmonary
veins
• LAD+ LVH in cyanotic 
Tricuspid atresia with
restrictive VSD, NRGA
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37. TRICUSPID ATRESIA CONT…
• Cause of LAD in tricuspid atresia: Not been firmly established
• Early arborization of left bundle accounts for LAD
• LVH 
• Deep S waves in right precordial leads and
• Tall R waves with repolarization abnormalities i.e inverted T
waves in leads aVL and V5-6
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38. TRICUSPID ATRESIA WITH TRANSPOSITION
• Typically occurs with a
nonrestrictive VSD and a well-
developed RV
• ↑PBF adds to LA volume Lt+ Rt
atria enlargement coexistP
waves broad, bifid, peaked
• Relatively well-developed RV
contributes to normal QRS axis
38

39. TRUNCUS ARTERIOSUS
• Tall, bifid, broad P waves
• ↓PBF QRS axis rightward
and clockwise depolarisation
• ↑PBF normal or Lt axis
• Precordial leads exhibit
biventricular hypertrophy
• (KATZ WACHTEL phenomenon)
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40. ECG FINDINGS IN TOF PHYSIOLOGY…
40

41. SO IN TOF PHYSIOLOGY…
• TOF: Cyanosis/ Murmur/No CHF/ RAD+
RVH/C-W loop/ Early transition from
V1 V2 (RVH with strain Strict NO NO)
• With LAD:
• AVCD with PS
• CC-TGA with PS
• TA
• With 1st deg AV block:
• AVCD with PS
• DORV, VSD, PS
• CC-TGA, VSD, PS
• No q in V5/V6: Single ventricle
• Q in V1, No Q in V6:
• CC-TGA, VSD, PS
• Extreme RAD:
• DORV, VSD, PS
• Associated ASD
41

42. LETS TRY THIS (6)…
• 1 month old child
• Acyonotic
• Severe respiratory distress
• DIAGNOSIS??
• LVH, LAD, CC-W LOOP
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43. ALCAPA
• 3 characteristic features:
• Deep narrow q waves: Leads 1, AVL
• LVH
• LAD
43

44. DEEP NARROW Q WAVES IN ALCAPA…
• Sometimes q waves in lead aVL
can equal or exceed height of
R wave
• Q waves rare in rt precordial
leads
44

45. ALCAPA CONT…
45
• Posterobasal region of LV selectively
increased in mass Capacity of
immature cardiomyocytes to replicate in
response to hypoxemia LVH + LAD
• Left atrial P wave abnormalities occur
because of mitral regurgitation

46. MI PATTERN IN ECG
• ALCAPA
• Kawasaki disease
• Myocarditis
• Pompe disease
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47. COMMENT ON P WAVES…
47

48. WHO COINED THE TERM??
• 1st female president of AHA
• Founder of Pediatric Cardiology
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49. EBSTEIN’S ANOMALY
Himalayan P waves: Prolonged aberrant conduction in enlarged RA
PR interval: Prolonged
Duration of PR interval and width of P wave correlate with prolonged conduction in
large RA
In presence of preexcitation PR interval usually but not invariably short
However, a short PR interval occasionally occurs without a delta wave and without
a history of paroxysmal rapid heart action
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50. EBSTEIN’S ANOMALY CONT…
• 75% to 95%: QRS characterized by RV conduction defect of RBB type
• QRS prolongation: Result of prolonged activation of atrialized RV
• Conduction defect is therefore distal to RBB and is sometimes present despite a
septal accessory pathway
• A distinctive second QRS complex originates in atrialized RV according to
intracardiac mapping
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51. EBSTEIN’S ANOMALY CONT…
• QRS axis is inferior: Although a splintered polyphasic QRS makes axis difficult to
determine
• LAD represents type B preexcitation
• Deep Q waves appear in leads 2, 3 and aVF but most important are right
precordial Q waves in lead V1 or in leads V1-4
• This distinctive Q wave pattern: Because precordial surface leads record RV
intracavitary potentials unusually far leftward as a result of large size of RA
• Prominent Q waves in right precordial leads can be misleading when adults with
Ebstein’s anomaly present with chest pain 51

52. EBSTEIN’S ANOMALY CONT…
• W-P-W preexcitation: 5% to 25%
• Downward displacement of septal tricuspid leaflet is accompanied by
discontinuity between central fibrous body and septal A-V ring Creates
substrate for preexcitation
• The only CCHD consistently associated with preexcitation, which is uniformly via
a right bypass tract (i.e., type B W-P-W)
• Combination of type B preexcitation+ cyanosis Presumptive evidence
• Accessory pathway conduction can be permanent/ intermittent and can occur
without delta waves
• SVT, A fib, AF: 25%- 30%
• Prolonged PR interval may progress to CHB
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53. EBSTEIN’S ECG POINTS…
53

54. VSD
Restrictive:
• Normal ECG
• Increased incidence of conduction disturbances if septal aneurysm
Moderately restrictive :
• Broad+ notched P wave in lead 1 and 2, Broad deep terminal force in lead V1
• Normal qrs axis
• LV overload: Tall R waves+ T waves in leads 2,3 and avF; Prominent q waves and
and R waves in V5-V6
54

55. VSD CONT…
Large unrestrictive:
Both Rt and Lt atrial P wave i.e broad and notched, abnormalities seen in leads
2 and V1-V2
QRS axis moderately shifts to right
Biventricular hypertrophy: Tall R waves in both rt and lt sided leads, large
equidiphasic waves in mid precordial leads (KATZ WACHTEL phenomenon)
Eisenmengerisation:
Normal or peaked p waves
RAD
Monophasic R waves in V1 and prominent S wave in Lt precordial leads
55

56. VSD CONT…
PERIMEMBRANOUS
VSD
INLET VSD MULTIPLE VSDs
With septal aneurysm-left
axis deviation
Counterclockwise loop,
LAD and prolonged PR
interval
Clockwise loop with left
axis deviation
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57. EISENMENGER’S SYNDROME
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58. CONCENTRATE ON MID PRECORDIAL LEADS
58

59. WHAT DO YOU THINK???
• 3 years old, asymptomatic kid, ESM pulmonary area, precordium:
Mildly hyperkinetic
• ECG: RAD+ Rsr in v1/ V3R
• DIAGNOSIS??
• Secundum ASD: RSR: 85-95%
59

60. SECUNDUM ASD
• Clockwise loop with vertical axis
• Right axis with PAH
• Left-axis deviation : Holt-Oram syndrome/LAHB
• RAE
• P wave axis-inferior and to left with upright p in inferior leads
• PR interval: May be prolonged, 1st degree AV block
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61. SECUNDUM ASD CONT…
• Wide QRS
• RBBB
• R’ In v1 and AVR is slurred
• Crochetage: Specific for ASD if present in all inferior leads
• Atrial fibrillation, Atrial flutter
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62. CROCHETAGE SIGN:R WAVE NOTCH
IN ALL INFERIOR LEADS
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63. FOLLOW UP
• PAH
• rsR’ gives way to R in v1
• Signs of PAH: RAD/RVH
• After surgery R may revert to rsR’ in 40% of patients
63

64. PRIMUM ASD
• Counterclockwise loop
• LAD
• PR prolongation
• RVH: Tall R in v1,deep s in v6
• Left A-V valve regurgitation: LVH
• Notching of s wave upstrokes in inferior leads
64

65. ASD HOW TO APPROACH
ASD
CLOCKWISE LOOP
SECUNDUM ASD: P -
wave axis
normal
Crochetage+
SV ASD: P- wave axis
superior
Crochetage+
COUNTER CLOCKWISE
LOOP
PRIMUM ASD: LAD
65

66. LETS SEE THIS CONDITION…
• Neonate with RDS, cyanosis, RVH with strain- Possibilities??
• TAPVC (Obstructed/ Unobstructed)
• PPHN
• Severe COA with BV dysfunction
66

67. A FEW WORDS ABOUT TAPVC
• Resembles secundum ASD
• PR interval tends to be prolonged
• A fib in older patients as it does with OS ASD
• Presence of pulmonary hypertension:
• Peaked right atrial P waves
• RAD
• Tall right precordial R waves
• Inverted T waves
• Deep left precordial S waves of RVH
67

68. LETS SEE THIS…
• Asymptomatic kid, prominent ESM over 2nd left space
• ECG: RVH, Tall R waves in V1/ V3R
• DIAGNOSIS??
• PS
• If ECG is: RSQ, THEN?????
• Dysplastic PV of Noonan’s Syndrome
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69. DCM/ MYOCARDITIS
• Recent onset CHF, insignificant murmur
• DIAGNOSTIC TRIAD (50%):
• Low voltage QRS
• ST segment+ T wave changes
• Tachycardia
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70. THANKS TO MY TEACHERS…
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