This document summarizes common ECG findings in various congenital heart diseases and rheumatic heart disease. In rheumatic heart disease, ECG findings may include PR interval prolongation, conduction abnormalities, arrhythmias, or P mitrale depending on the structures involved and extent of cardiac damage. In mitral valve prolapse, ECG changes can include first degree AV block in 6-19% of patients. Common ECG patterns are described for various congenital heart defects including ventricular septal defects, patent ductus arteriosus, Ebstein's anomaly, tetralogy of Fallot, transposition of the great arteries, pulmonary stenosis, and more.

1. ECG CHANGES IN RHD, MVP AND
CONGENITAL HEART DISEASES
PRESENTER: DR. AYUSHI MUNGAD
MODERATOR: DR M.K. JAIN SIR

2. RHEUMATIC HEART DISEASE
ON ECG, RHEUMATIC FEVER IS CHARACTERIZED BY :
• PR INTERVAL PROLONGATION,
• CONDUCTION ABNORMALITIES,
• ARRYHTHMIAS, OR P MITRALE
• DEPENDING ON THE STRUCTURES INVOLVED AND THE EXTENT OF
CARDIAC DAMAGE

3. • ECG CHANGES DEPEND ON THE STRUCTURES INVOLVED AND THE
EXTENT OF CARDIAC DAMAGE. THE FOLLOWING ECG CHANGES MAY BE
NOTED IN PATIENTS WITH RHEUMATIC FEVER:
• SINUS TACHYCARDIA OR BRADYCARDIA DEPENDING ON VAGAL TONE
• PROLONGATION OF PR INTERVAL
• VARIABLE DEGREE OF AV CONDUCTION BLOCK

4. • P MITRALE SECONDARY TO MITRAL VALVE ABNORMALITIES
• MITRAL VALVE ABNORMALITIES MAY LEAD TO DEVELOPMENT
OF ATRIAL FLUTTER OR ATRIAL FIBRILLATION
• T-WAVE INVERSIONS WHICH MAY BE NOTED IN LEADS I, II AND IV
SUGGESTIVE OF PERICARDIAL INVOLVEMENT.
• ST SEGMENT ELEVATION MAY ALSO BE PRESENT IN LEADS II, III, AVF
AND V4 TO V6 IN PATIENTS WITH ACUTE PERICARDITIS

6. MITRAL VALVE PROLAPSE

7. SECUNDUM ATRIAL SEPTAL DEFECT
• RHYTHM: NORMAL SINUS RHYTHM, INCREASED RISK OF AF WITH AGE
• PR INTERVAL: FIRST DEGREE AV BLOCK IN 6-19%
• QRS AXIS: 0° TO 180°; RAD; LAD IN HOLT-ORAM OR LAHB

8. SECUNDUM ATRIAL SEPTAL DEFECT
• QRS CONFIGURATION: RSR´ OR RSR´ WITH RBBBI>RBBBC
• ATRIAL ENLARGEMENT: RAE 35%
• VENTRICULAR HYPERTROPHY: UNCOMMON
• PARTICULARITIES: "CROCHETAGE" PATTERN

9. VENTRICULAR SEPTAL DEFECT
• RHYTHM: NORMAL SINUS RHYTHM, PVCS
• PR INTERVAL: NORMAL OR MILD ↑; 1° AVB 10%
• QRS AXIS: RAD WITH BVH; LAD 3% TO 15%

10. VENTRICULAR SEPTAL DEFECT
• QRS CONFIGURATION: NORMAL OR RSR´; POSSIBLE RBBB
• ATRIAL ENLARGEMENT: POSSIBLE RAE±LAE
• VENTRICULAR HYPERTROPHY: BVH 23% TO 61%; RVH WITH
EISENMENGER
• PARTICULARITIES: KATZ-WACHTEL PHENOMENON

11. PATENT DUCTUS ARTERIOSUS
• RHYTHM: NORMAL SINUS RHYTHM, ↑ IART/AF WITH AGE
• PR INTERVAL: ↑ PR 10% TO 20%
• QRS AXIS: NORMAL

12. PATENT DUCTUS ARTERIOSUS
• QRS CONFIGURATION: DEEP S V1, TALL R V5 AND V6
• ATRIAL ENLARGEMENT: LAE WITH MODERATE PDA
• VENTRICULAR HYPERTROPHY: UNCOMMON
• PARTICULARITIES: OFTEN EITHER CLINICALLY SILENT OR EISENMENGER

13. EBSTEIN’S ANOMALY
• RHYTHM: NORMAL SINUS RHYTHM, POSSIBLE EAR, SVT; AF/IART 40%
• PR INTERVAL: 1° AVB COMMON; SHORT IF WPW
• QRS AXIS: NORMAL OR LAD

14. EBSTEIN’S ANOMALY
• QRS CONFIGURATION: LOW-AMPLITUDE MULTIPHASIC ATYPICAL RBBB
• ATRIAL ENLARGEMENT: RAE WITH HIMALAYAN P WAVES
• VENTRICULAR HYPERTROPHY: DIMINUTIVE RV
• PARTICULARITIES: ACCESSORY PATHWAY COMMON; Q II, III, AVF, AND V1–V4

15. SURGICALLY REPAIRED TOF
• RHYTHM: NORMAL SINUS RHYTHM, PVCS; IART 10%; VT 12%
• PR INTERVAL: NORMAL OR MILD ↑
• QRS AXIS: NORMAL OR RAD; LAD 5% TO 10%

16. SURGICALLY REPAIRED TOF
• QRS CONFIGURATION: RBBB 90%
• ATRIAL ENLARGEMENT: PEAKED P WAVES; RAE POSSIBLE
• VENTRICULAR HYPERTROPHY: RVH POSSIBLE IF RVOT OBSTRUCTION
OR PHT
• PARTICULARITIES: QRS DURATION±QTD PREDICTIVE OF VT/SCD

17. COMPLETE TGA/INTRA-ATRIAL BAFFLE
• RHYTHM: SINUS BRADY 60%; EAR; JUNCTIONAL; IART 25%
• PR INTERVAL: NORMAL
• QRS AXIS: RAD

18. COMPLETE TGA/INTRA-ATRIAL BAFFLE
• QRS CONFIGURATION: ABSENCE OF Q, SMALL R, DEEP S IN LEFT
PRECORDIUM
• ATRIAL ENLARGEMENT: POSSIBLE RAE
• VENTRICULAR HYPERTROPHY: RVH; DIMINUTIVE LV
• PARTICULARITIES: POSSIBLE AVB IF VSD OR TV SURGERY

19. PULMONARY STENOSIS
• RHYTHM: NORMAL SINUS RHYTHM
• PR INTERVAL: NORMAL
• QRS AXIS: NORMAL IF MILD; RAD WITH
MODERATE/SEVERE

20. PULMONARY STENOSIS
• QRS CONFIGURATION: NORMAL; OR RSR´; R´ INCREASES WITH
SEVERITY
• ATRIAL ENLARGEMENT: POSSIBLE RAE
• VENTRICULAR HYPERTROPHY: RVH; SEVERITY CORRELATES WITH R:S IN
V1 AND V6
• PARTICULARITIES: AXIS DEVIATION CORRELATES WITH RVP

21. CONGENITALLY CORRECTED TGA
• RHYTHM: NORMAL SINUS RHYTHM
• PR INTERVAL: 1° AVB >50%; AVB 2%/YEAR
• QRS AXIS: LAD

22. CONGENITALLY CORRECTED TGA
• QRS CONFIGURATION: ABSENCE SEPTAL Q; Q IN III, AVF, AND RIGHT
PRECORDIUM
• ATRIAL ENLARGEMENT: NOT IF NO ASSOCIATED DEFECTS
• VENTRICULAR HYPERTROPHY: NOT IF NO ASSOCIATED DEFECTS
• PARTICULARITIES: ANTERIOR AVN; POSITIVE T PRECORDIAL; WPW WITH
EBSTEIN’S

23. COMPLETE TGA/INTRA-ATRIAL BAFFLE
• RHYTHM: SINUS BRADY 60%; EAR; JUNCTIONAL; IART 25%
• PR INTERVAL: NORMAL
• QRS AXIS: RAD

24. COMPLETE TGA/INTRA-ATRIAL BAFFLE
• QRS CONFIGURATION: ABSENCE OF Q, SMALL R, DEEP S IN LEFT
PRECORDIUM
• ATRIAL ENLARGEMENT: POSSIBLE RAE
• VENTRICULAR HYPERTROPHY: RVH; DIMINUTIVE LV
• PARTICULARITIES: POSSIBLE AVB IF VSD OR TV SURGERY

25. AORTIC COARCTATION
• RHYTHM: NORMAL SINUS RHYTHM
• PR INTERVAL: NORMAL
• QRS AXIS: NORMAL OR LAD
• QRS CONFIGURATION: NORMAL

26. AORTIC COARCTATION
• ATRIAL ENLARGEMENT: POSSIBLE LAE
• VENTRICULAR HYPERTROPHY: LVH, ESPECIALLY BY VOLTAGE CRITERIA
• PARTICULARITIES: PERSISTENT RVH RARE BEYOND INFANCY

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