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Electrocardiogram in Asymptomatic Acyanotic Congenital Heart Disease

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Insights into Electrocardiograms with MCQs

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Abstract

Nowadays, diagnosis of congenital heart disease is dependent on detailed echocardiographic evaluation. However, electrocardiogram is still an integral part of diagnosis of congenital heart disease. Clinical examination combined with an electrocardiogram are very useful in arriving at reasonable differential diagnosis in an asymptomatic, acyanotic patient with congenital heart disease. A clinico-electrocardiographic approach for differential diagnosis is discussed with representative electrocardiograms. Flow charts at the end of the chapter help in easy memorization of this approach. Summary and MCQs at the end of the chapter help in quick revision and self-assessment.

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Author information

Authors and Affiliations

  1. Ex Senior professor and head of the department of cardiology, Jawaharlal Nehru Medical College, Ajmer, India

    Sitaram Mittal

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  1. Sitaram Mittal
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Appendices

Summary

  • Several congenital cardiovascular anomalies may have no appreciable electrocardiographic abnormality. Therefore, a normal electrocardiogram cannot categorically exclude the possibility of a congenital cardiovascular disease.

  • Isolated congenital abnormalities of sinus node function, atrioventricular conduction, intraventricular conduction, or QT interval may be present without appreciable clinical findings.

  • Congenital complete atrioventricular block may occur as an isolated anomaly or as a part of inversion of the ventricles.

  • rsr’ or rsR’ in lead V1 with right axis deviation suggests moderately large left to right shunt at the atrial level. Additional inversion of the P waves in leads II, III, and aVF suggest the possibility of superior vena cava sinus venosus atrial septal defect. rsr’ or rsR’ in lead V1 with left axis deviation suggests the possibility of ostium primum ASD.

  • Prominent q wave with tall R wave and upright T wave in leads V4/ V5/V6 suggest chronic left ventricular volume overload and the possibility of moderate left to right shunt across a ventricular septal defect or patent ductus arteriosus. Additional rsr’ in lead V1 suggests the possibility of left ventricle to right atrial shunt.

  • Left axis deviation suggests the possibility of atrioventricular septal defect or Noonan’s syndrome. Atrioventricular septal defect can present as mitral regurgitation, ostium primum ASD, or VSD.

  • Prominent R wave with flat T wave and no prominence of q wave in leads V5/V6 suggest pressure overload of the left ventricle. This can happen in moderate coarctation of the aorta with systemic hypertension, subaortic membrane with moderate gradient, or moderate aortic valve stenosis.

  • Prominent R wave with deep symmetrical T wave inversion in leads V4 to V6 should raise suspicion of hypertrophic cardiomyopathy.

  • Right axis deviation, tall peaked P waves, and prominent R with T wave inversion in leads V1 to V 3 suggest the possibility of moderately severe valvular pulmonary stenosis with intact interventricular septum.

  • Right axis deviation, prominent R wave in lead V1, sudden transition to RS pattern in lead V2, and persistence of small q wave and normal R wave in leads V5 and V6 should raise suspicion of acyanotic (pink) tetralogy of Fallot.

  • Peaked tall P wave and splintered small QRS in lead V1 should suggest the possibility of mild Ebstein’s anomaly.

A flowchart for asymptomatic acynotic C H D goes through normal clinical examination to E C G to determine whether it is normal or there are abnormalities of the P wave, Q R S complexes, P R interval, and Q T interval.
A flowchart for systolic murmur along left upper sternal border goes through E C G to check the normal or r s r' in V subscript 1 with Q R S axis around + 90 degrees, r s r' in V superscript 1, R A D, R in V subscript 1, peaked P in 2, 3, a V F, L A D, and leads V subscript 5, V subscript 6.
A flowchart for systolic murmur along left lower parasternal region goes through E C G to check for normal, Q R S axis + 90 degrees to + 120 degrees, and leads V 5, V 6.
A flowchart for systolic murmur along right upper sternal border goes through E C G to normal, mild valvular A S, and mild supravalvular A S.
A flowchart for systolic murmur on both sides of upper sternum goes through E C G to normal and bilateral pulmonary artery branch stenosis.
A flowchart for systolic murmur over cardiac apex goes through E C G to normal with mild M R, prominent q tall R and positive T in V 5 and V6 with moderately severe M R, and left axis deviation with M R as a part of atrioventricular septal defect.
A flowchart for systolic murmur over lung fields goes through E C G to normal, pulmonary arteriovenous fistula, and peripheral pulmonary artery branch stenosis.
A flowchart for continuous murmur over long fields is divided into over left first space and over either side of sternum. Over left first space goes through E C G to determine whether normal or there is prominent q, prominent R, and positive T in leads V 5 and V 6, while over either side of sternum goes through E C G to normal, coronary arteriovenous fistula, and systemic arteriovenous fistula.

MCQs

Q1. Persistent left superior vena cava draining into the coronary sinus produces:

  1. (a)

    Right atrial enlargement

  2. (b)

    Right ventricular enlargement

  3. (c)

    Right axis deviation

  4. (d)

    Normal electrocardiogram

Q2. Isolated right aortic arch produces:

  1. (a)

    No signs

  2. (b)

    Pulsations in right second intercostal space

  3. (c)

    Pulsations in the right supraclavicular region

  4. (d)

    Continuous murmur over right 1st intercostal space

Q3. Congenital absence of hepatic portion of the inferior vena cava with azygos continuation produces:

  1. (a)

    No signs

  2. (b)

    Edema in lower limbs

  3. (c)

    Hepatomegaly

  4. (d)

    Increased pressure in superior vena cava

Q4. Absence of any abnormal clinical findings excludes:

  1. (a)

    Narrow patent ductus arteriosus

  2. (b)

    Patent foramen ovale

  3. (c)

    Small ventricular septal defect

  4. (d)

    Single coronary artery

Q5. Congenital complete absence of pericardium produces:

  1. (a)

    Prominent apical impulse

  2. (b)

    Prominent right ventricular pulsation

  3. (c)

    Increased amplitude of QRS in leads V5 and V6

  4. (d)

    Shifting of the heart to the left

Q6. Isolated anomalous drainage of the right upper pulmonary vein in the right atrium produces:

  1. (a)

    Right atrial enlargement

  2. (b)

    Right axis deviation

  3. (c)

    Rsr’ in lead V1

  4. (d)

    None of the above

Q7. Anomalous origin of the right coronary artery from the left main coronary artery produces:

  1. (a)

    ST-segment elevation in lead V3R

  2. (b)

    ST-segment depression in leads V5 and V6

  3. (c)

    Right ventricular failure

  4. (d)

    None of the above

Q8. Idiopathic dilatation of the right atrium produces:

  1. (a)

    Systemic venous congestion

  2. (b)

    Tall P waves in leads II and V1

  3. (c)

    qR in lead V1

  4. (d)

    Normal electrocardiogram

Q9. Electrocardiographic findings of isolated inversion of the ventricles include:

  1. (a)

    Right axis deviation

  2. (b)

    Tall P waves in leads II and V1

  3. (c)

    Left bundle branch block

  4. (d)

    q wave in lead V1 and absence of the q wave in lead V6

Q10. Small secundum atrial septal defect with small left to right shunt produces:

  1. (a)

    Right axis deviation

  2. (b)

    Incomplete right bundle branch block

  3. (c)

    Wide and fixed split of second heart sound

  4. (d)

    None of the above

Q11. Nonobstructive congenital mitral stenosis produces:

  1. (a)

    No clinical abnormality

  2. (b)

    Mid diastolic murmur over cardiac apex

  3. (c)

    Broad and notched P wave in lead II

  4. (d)

    Right axis deviation

Q12. Isolated tricuspid valve prolapse can be excluded confidently by:

  1. (a)

    Thorough clinical examination

  2. (b)

    Surface electrocardiogram

  3. (c)

    a+b

  4. (d)

    None of above

Q13. Normal clinical examination and normal surface electrocardiogram can exclude the presence of:

  1. (a)

    Isolated tricuspid valve prolapse

  2. (b)

    Patent foramen ovale

  3. (c)

    Restrictive ventricular septal defect

  4. (d)

    Papillary muscle hypertrophy

Q14. Normal clinical examination and normal electrocardiogram cannot exclude the presence of:

  1. (a)

    Congenital aneurysm of the left ventricle

  2. (b)

    Persistence of fetal circulation

  3. (c)

    Ostium primum atrial septal defect

  4. (d)

    Patent ductus arteriosus with large left to right shunt

Q15. Inversion of the P waves in leads I, V5, and V6 suggest:

  1. (a)

    Situs inversus

  2. (b)

    Left atrial rhythm

  3. (c)

    Low atrial rhythm

  4. (d)

    Situs solitus

Q16. Inversion of the P waves inversion in leads I, aVL, and positive P wave in lead aVR suggest:

  1. (a)

    Situs inversus

  2. (b)

    Left atrial rhythm

  3. (c)

    Reversal of arm leads

  4. (d)

    Reversal of left upper limb and left lower limb leads

Q17. “Dome and dart” P waves in lead V1 suggest:

  1. (a)

    Left atrial rhythm

  2. (b)

    Low atrial rhythm

  3. (c)

    Situs inversus

  4. (d)

    Right ventricular hypertrophy

Q18. qR in lead V1 and rS in lead V6 with normal P waves suggest:

  1. (a)

    Dextrocardia

  2. (b)

    Right bundle branch block

  3. (c)

    Right ventricular hypertrophy

  4. (d)

    Right ventricular volume overload

Q19. q wave in leads V1 to V4R and the absence of q wave in leads V5 to V9 suggest:

  1. (a)

    Congenitally corrected transposition of the great arteries

  2. (b)

    D transposition of the great arteries

  3. (c)

    Biventricular enlargement

  4. (d)

    Dextroposition

Q20. Prominent R waves with deep inversion of the T waves in leads V4 to V6 without any significant clinical finding in an asymptomatic person suggests the possibility of:

  1. (a)

    Hypertrophic cardiomyopathy

  2. (b)

    Severe left ventricular outflow tract obstruction

  3. (c)

    Severe coarctation

  4. (d)

    Anterolateral myocardial infarction

Q21. Which conditions may not produce any appreciable clinical findings:

  1. (a)

    Isolated first degree atrioventricular block

  2. (b)

    Ebstein anomaly

  3. (c)

    Hereditary long QT syndrome

  4. (d)

    None of the above

Q22. Isolated congenital complete atrioventricular block in a neonate produces:

  1. (a)

    Feeding difficulty

  2. (b)

    Tachypnoea

  3. (c)

    Hypotension

  4. (d)

    None of the above

Q23. Pectus excavatum alone can produce:

  1. (a)

    Prominent left parasternal lift

  2. (b)

    Grade 2–3/6 systolic murmur in the left second intercostal space

  3. (c)

    Prominent systolic pulsations in right second intercostal space

  4. (d)

    Nonejection click

Q24. The electrocardiogram is normal in:

  1. (a)

    Primum atrial septal defect

  2. (b)

    Idiopathic dilatation of the pulmonary artery

  3. (c)

    Straight back

  4. (d)

    Origin of left coronary artery from the pulmonary artery

Q25. rSr’ configuration in lead V1 with right axis deviation and inversion of the P waves in leads II, III, and aVF suggest:

  1. (a)

    Atrioventricular septal defect

  2. (b)

    Superior vena cava sinus venosus atrial septal defect

  3. (c)

    Inferior vena cava sinus venosus atrial septal defect

  4. (d)

    Coronary sinus type atrial septal defect

Q26. Deep S wave in lead V1 with tall R waves, deep narrow q waves, and positive T waves in leads V5 and V6 suggest the possibility of:

  1. (a)

    Moderate size VSD with moderate left to right shunt

  2. (b)

    VSD with severe pulmonary stenosis

  3. (c)

    Left ventricle to right atrial shunt

  4. (d)

    VSD with severe pulmonary artery hypertension

Q27. Deep S waves in leads V1,V2 with tall R waves, small or no q waves, and flat T waves in leads V5 and V6 support the possibility of:

  1. (a)

    Moderate subvalvular membranous aortic stenosis

  2. (b)

    Apical hypertrophic cardiomyopathy

  3. (c)

    Supracristal VSD with moderate left to right shunt

  4. (d)

    Moderate right ventricular infundibular stenosis

Q28. Grade 2/6 short systolic murmur in the left lower parasternal region in an asymptomatic acyanotic neonate with right ventricular dominance in electrocardiogram suggest:

  1. (a)

    Normal tricuspid regurgitation

  2. (b)

    Still’s murmur

  3. (c)

    Organic tricuspid regurgitation

  4. (d)

    Small muscular VSD

Q29. Right axis deviation, prominent R wave in lead V1, rS in lead V2, and small q wave with well-developed R wave in lead V6 in an acyanotic child suggests:

  1. (a)

    Supracristal VSD with pulmonary artery hypertension

  2. (b)

    Inlet VSD with pulmonary valve stenosis

  3. (c)

    PDA with pulmonary artery hypertension

  4. (d)

    Perimembranous VSD with overriding of the aorta

Q30. Systolic murmur in the left lower parasternal region with right axis deviation, peaked tall P waves, and small, splintered QRS in lead V1 suggest:

  1. (a)

    LV to RA shunt

  2. (b)

    Right ventricular hypertrophy with tricuspid regurgitation

  3. (c)

    Ebstein anomaly

  4. (d)

    VSD with prolapse of the septal leaflet of the tricuspid valve in the defect

Q31. Systolic murmur over the cardiac apex in an asymptomatic infant with normal electrocardiogram supports the possibility of mitral regurgitation due to:

  1. (a)

    Mitral valve prolapse

  2. (b)

    Atrioventricular septal defect

  3. (c)

    Anomalous left coronary artery from pulmonary artery

  4. (d)

    Endocardial fibroelastosis

Q32. Systolic murmur over the right second intercostal space in an asymptomatic, infant with normal electrocardiogram supports the possibility of:

  1. (a)

    Mild supravalvular aortic stenosis

  2. (b)

    Right aortic arch

  3. (c)

    Corrected transposition of great arteries with pulmonary valve stenosis

  4. (d)

    Right pulmonary artery stenosis

Q33. Continuous murmur over the left interscapular region in an asymptomatic, acyanotic child with normal electrocardiogram is likely to be due to:

  1. (a)

    Coarctation of aorta

  2. (b)

    Bronchopulmonary collaterals

  3. (c)

    Pulmonary arteriovenous fistula

  4. (d)

    Peripheral pulmonary artery stenosis

Q34. Continuous murmur over the right parasternal region in an asymptomatic child with normal electrocardiogram suggests the possibility of:

  1. (a)

    Coronary arteriovenous fistula opening in the right atrium

  2. (b)

    Rupture of sinus of Valsalva aneurysm in right atrium

  3. (c)

    Pulmonary arteriovenous fistula

  4. (d)

    Systemic arteriovenous fistula

Q35. Continuous murmur over the left sternal border in an asymptomatic child with normal electrocardiogram suggests the possibility of:

  1. (a)

    Coronary arteriovenous fistula opening in the right ventricle

  2. (b)

    Rupture of sinus of Valsalva aneurysm in the right ventricle

  3. (c)

    Aorto-pulmonary window

  4. (d)

    Cor triatriatum

Q36. Continuous murmur over the left first intercostal space in an asymptomatic infant with normal electrocardiogram suggests the possibility of:

  1. (a)

    Large PDA

  2. (b)

    Venous hum

  3. (c)

    Stenosis of the left subclavian artery

  4. (d)

    Left pulmonary artery stenosis

Answers

(1)d (2)a (3)a (4)c (5)d (6)d (7)d (8)d (9)d (10)(d) (11) a (12)d (13)c (14)a (15)b (16)a,c (17)a (18)a (19), (20)a (21)a,b,c (22)d (23)a,b (24)b,c (25)b (26)a (27)a (28)a (29)d (30)c (31)a (32)a (33)c,d (34)a,c (35)a (36)b

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Mittal, S. (2023). Electrocardiogram in Asymptomatic Acyanotic Congenital Heart Disease. In: Insights into Electrocardiograms with MCQs. Springer, Singapore. https://doi.org/10.1007/978-981-99-0127-2_48

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  • DOI: https://doi.org/10.1007/978-981-99-0127-2_48

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