1. ECG Rounds: Dr. Dave Dyck R3 April 3, 2003

2. Case 1:  2 week infant with tachypnea (RR=60-70), tachycardia (170) and “dusky” in appearance.

4. Cardiologists Interpretation:  Sinus rhythm. Heart Rate 160.  QRS axis 90. PR 130ms. QRS 50ms. QT/QTc 280/450  Right atrial hypertrophy  Right ventricular hypertrophy  LV strain/ischaemia

6. Of Note:  The T wave changes are the most significant features of this ECG.  An upright T wave in V1 in a 2 week old infant is abnormal and may signify RV systolic hypertension.  Inverted T waves in V5-6 are evidence of LV strain which may cause reciprocally upright T waves in the right chest leads.  (TGA/VSD/PA)

7. Case 2:  13m female with failure to thrive and worsening tachypnea sent to ER by GP  HR=125 RR=42 O2sat=94%

8. ECG:

9. Cardiologist’s Interpretation:  Sinus rhythm. Rate 124. QRS axis +150. PR 150ms. QRS 60ms. QT/QTc 240/340 Bi-atrial hypertrophy, left >right Right axis deviation Right ventricular hypertrophy  (upright T waves in V1= abnormal)

10. ECG:

11. Of Note:  This young child was born with a dysmorphic mitral valve which has resulted in both mitral stenosis and incompetance.  The right sided hypertrophy is a result of pulmonary hypertension caused by her elevated left heart pressures.

12. Pediatric ECGs  Often 13 lead ECGs done (V3R or V4R) for the evaluation of RVH in children

13. V1 inverted Ts:  1 st day = RAD, large R waves + upright T waves in right precordial leads (V3R, V1)  by 48 hrs: inverted T waves in V1, V3R  Upright Ts > 1 wk  pathologic (RVH or strain)  Should never be upright before age 6 and often into adolescence

14. Axis:  Newborn Axis: usually +110 - +180  V1, V3R have R>S wave usually and often for months/years (up to 8 yrs)  Over the years, the QRS axis gradually shifts leftward and right ventricular forces slowly regress  If it looks like a normal adult ECG early on think LVH

15. Pediatric Heart Chamber Hypertrophy:  Right Atrial Enlargement (RAE): P wave > 2 mm tall in infants and small children and > 3 mm tall in older children P waves best seen in inferior (I,II & aVF) and the right chest leads (V3R, V1 & V2)

16. RAE:

17. Left Atrial Enlargement:  Wide P waves > 2 mm wide (.08s) in infants and small children and more than 3 mm wide (.12s) in larger children  Best seen in inferolateral leads

18. LAE:

19. P wave morphology in AE:

20. Right Ventricular Hypertrophy:  R in V1 >95% of normal + S in V6 deeper than 95% of normal

21. AgeHR bpm QRS axis degrees PR interval seconds QRS interval seconds R in V1 mm S in V1 mm R in V6 mm S in V6 mm 1st week90-16060-1800.08-0.150.03-0.085-260-230-120-10 1-3wks100-18045-1600.08-0.150.03-0.083-210-162-160-10 1-2 mo120-18030-1350.08-0.150.03-0.083-180-155-210-10 3-5 mo105-1850-1350.08-0.150.03-0.083-200-156-220-10 6-11 mo110-1700-1350.07-0.160.03-0.082-200.5-206-230-7 1-2 yr90-1650-1100.08-0.160.03-0.082-180.5-216-230-7 3-4 yr70-1400-1100.09-0.170.04-0.081-180.5-214-240-5 5-7 yr65-1400-1100.09-0.170.04-0.080.5-140.5-244-260-4 8-11 yr60-130-15-1100.09-0.170.04-0.090-140.5-254-250-4 12-15 yr65-130-15-1100.09-0.180.04-0.090-140.5-214-250-4 > 16 yr50-120-15-1100.12-0.200.05-0.100-140.5-234-210-4

22. RVH #2  rsR’ in V1 & V2 without a widened QRS duration as in RBBB (note= 2 nd R is larger)

23. RVH #3  qR in V1 and V2

24. RVH #4  Pure R in V1 & V2 +/- strain changes

25. Left Ventricular Hypertrophy (LVH):  S in V1 deeper than 95% of normal and R in V6 taller than 95% of normal

26. Summary:  From 5 days to age 6, upright T waves in V1 are abnormal.  RAD (& V3R, V1 R>S) is prominent early and is normal  RVH in kids 1. R in V1>95% of normal and S in V6 deeper than 95% 2. RsR’ in V1(2) without widened QRS 3. qR in V1(2) 4. pure R in V1(2) +/- strain  Ventricular hypertrophy in children is based on comparison to statistical norms