ECG in congenital heart diseases - Trần Công Bảo Phụng

ECG IN CONGENITAL 
HEART DISEASES 
Dr TRẦN CÔNG BẢO PHỤNG, CHILDREN HOSPITAL N1 
• ECG IN COMMON CONGENITAL HEART DISEASES 
• ARRYTHMIAS AFTER OPEN HEART SURGERIES 
ASD 
 Small ASD: normal ECG 
 Large ASD : RAD, RAH, 
RVH±RBBB or 1st degree AV block 
VSD 
. 
 Small VSD, ECG is normal. 
 Moderate VSD: LVH and occasional left LAH. 
 Large defect: BVH with or without LAH. 
 If pulmonary vascular obstructive disease 
develops, the ECG shows RVH only. 
VSD 
Large vsd / 3 months baby: LVH, RVH 
PDA 
 Similar to those in VSD. 
 A normal ECG or LVH with small to 
moderate PDA. 
 BVH with large PDA. 
 If pulmonary vascular obstructive 
disease develops, RVH is present. 
TOF 
1. Right axis deviation (RAD) 
(+120 to +150 degrees). 
2. RVH. BVH in the acyanotic 
form. RAH is occasionally 
present. 
EBSTEIN 
1. RBBB and RAH 
2. First-degree AV block in 40% of 
patients. A WPW pattern in 15% to 
20% of patients with occasional 
episodes of SVT. 
EBSTEIN 
Tracing from a 5-year-old child with Ebstein's anomaly. The tracing shows right atrial 
hypertrophy, right bundle branch block, and first-degree atrioventricular block 
PS 
Mild: normal ECG. 
Moderate PS: Right axis deviation (RAD) and 
RVH. The degree of RVH on the ECG correlates 
with the severity of PS. 
Neonates with critical PS may show LVH because 
of a hypoplastic RV and relatively large LV 
PAIVS 
 The QRS axis is normal (i.e., +60 to +140 
degrees), in contrast to the superiorly 
oriented QRS axis seen in tricuspid atresia. 
 LVH. Occasionally, RVH is seen in infants 
with a relatively large RV cavity. RAH 
DORV 
 Subaortic VSD without PS: resembles ECDc. 
Superior QRS axis. RVH or BVH, LAH. 1st 
degree AV block. 
 Subaortic VSD with pulmonary stenosis 
(Fallot type): RAD, RAH, RVH, or RBBB. 
1st degree AV block 
 Subpulmonary VSD (Taussig-Bing 
syndrome): RAD, RAH, and RVH. LVH: 
during infancy 
AVSD 
 “Superior” QRS axis with the QRS axis 
between -40 and -150 degrees is 
characteristic of the defect . 
Most of the patients have a prolonged PR 
interval (first-degree AV block). 
RVH or RBBB is present in all cases, and 
many patients have LVH. 
AVSD 
Tracing from a 5-year-old boy with Down syndrome and complete atrioventricular canal. Note the 
“superior” QRS axis (-110 degrees) and right ventricular hypertrophy 
TGA 
Rightward QRS axis ( +90 to +200 degrees). 
RVH is usually present after the first few days 
of life. 
Biventricular hypertrophy (BVH) with large 
VSD, PDA, or PAH. 
Occasionally RAH. 
TGA 
 ECG tracing from a 6-day-old male infant with complete transposition of the great arteries. The 
QRS axis is +140 degrees. Note the deep S waves in V5 and V6 and an upright T wave in V1. 
 ALCAPA 
Anterolateral myocardial infarction 
pattern: abnormally deep and wide Q 
waves, inverted T waves, and an ST-
segment shift in leads I and aVL and 
the precordial leads 
 Early postoperative arrhythmias 
Hemodynamically significant arrhythmias are frequent in the early days after 
pediatric cardiac surgery, affecting perhaps 15–20% of cases overall 
• Sinus tachycardia 
• Junctional ectopic tachycardia 
• Atrial tachycardia and atrial flutter 
• Sinus bradycardia 
• Ventricular premature beats 
• ventricular tachycardia 
• Ventricular fibrillation 
• Postoperative complete AV 
block 
Sinus tachycardia 
Junctional ectopic tachycardia 
Adenosin reveal JET 
3 years old boy after double switch for L TGA: atrial flutter 
Neonate after TAPVC repair: PAC recovered with oral propanolol 
Ventricular tachycardia in 5 year old girl after RVO conduit replacement 
Complete AV block in 18 months old girl after resection of severve fibromuscular subaortic stenosis 
Late postoperative arrhythmias 
The main arrhythmias of concern are incisional atrial tachycardia (atrial 
flutter), sinoatrial disease, and ventricular tachycardia 
• Arrhythmias after the Senning and Mustard operations 
• Arrhythmias after repair of a tetralogy of Fallot 
• Arrhythmias after the Fontan operation 
Arrhythmias after the Senning and Mustard operations 
Sinus bradycardia 
Atrial flutter 
Arrhythmias after the Senning and Mustard operations 
Atrial flutter 
Arrhythmias after repair of TOF 
• Significant arrhythmias are uncommon in the early years after repair of a 
tetralogy of Fallot but they become increasingly prevalent late on. 
• Often related to significant haemodynamic abnormalities, such as PR, 
impaired RV function, and TR. 
• The most common arrhythmias are AT (flutter or fibrillation) and VT. 
• RBBB  an atrial arrhythmia. LBBB  ventricular tachycardia 
Arrhythmias after repair of TOF 
Atrial flutter 
Arrhythmias after repair of TOF 
Atrial flutter 
Arrhythmias after repair of TOF 
Atrial flutter 
Arrhythmias after repair of TOF 
Ventricular tachycardia 
Arrhythmias after repair of TOF 
Ventricular tachycardia 
Arrhythmias after the Fontan operation 
• Late arrhythmia is common involves loss of sinus rhythm with 
bradycardia or incisional atrial macro re-entry tachycardia, as atrial flutter. 
• The substrate for tachycardia is provided by right atrial dilation and 
hypertrophy plus scarring from previous surgery. 
Arrhythmias after the Fontan operation 
7-year-old boy with SVT after Fontain operation: 1: 1 AV relationship 
Arrhythmias after the Fontan operation 
Fews minutes later : 2: 1 AV conduction  atrial tachycardia, not accessory pathway 
Thank you for your attention!