Electrocardiography on

Congenital Heart Disease

Davit Soesanto
 Elektrokardiografi
Heart Rate
Irama
Axis QRS
Gelombang P : Amplitudo dan Durasi

Gelombang P abnormal

Interval PR dan Gangguan Konduksi

Gelombang Q abnormal RUANG
JANTUNG
Kompleks QRS : Interval QRS

Kompleks QRS abnormal

R/S ratio

QT interval, QTc interval

Segment ST
Gelombang T abnormal
Gelombang U
 AXIS
2 Bioelectrical approach of ECG
HEXAXIAL
HEXAXIAL REFERENCE
REFERENCE SYSTEM
SYSTEM HORIZONTAL
HORIZONTAL
(Heart
(Heart AXIS)
AXIS) REFERENCE
REFERENCE SYSTEM
SYSTEM
view
view from
from frontal
frontal view
view from
from cranial
cranial
CRANIAL
CRANIAL
POSTERIOR
POSTERIOR

-- - -
Spine
Spine

-
RIGHT
RIGHT
- LEFT
LEFT
+ V6
RIGHT
RIGHT LEFT
LEFT
+ V5
ANTERIOR
ANTERIOR

+ + +
+ V4
V1 V2 V3
CAUDAL
CAUDAL

Aug 2009 Eka Gunawijaya 3

AXIAL approach of normal ECG

LA
LA
SA
SA node
node
Many
Many VECTORs
VECTORs of of
RA
RA heart bioelectrical
heart bioelectrical

AV
AV node
node

LV
LV

RV
RV

AXIS
AXIS ++ 60
60 degrees
degrees

AXIAL
AXIAL
(Summation
(Summation of
of all
all VECTORs)
VECTORs)
4
 Heart AXIS LAD = Left axis
LAD deviation

Extreme
RAD -90
+240 +270 -60
aVR aVL
Q
ua

3
+210 d -30

t-
ra

an
nt

dr
-4

ua
Q
RAD = Right 0 I
+180
axis deviation Q
ua

-1
d

nt
ra

ra
nt

d
-2

ua
+150 +30

Q
Normal axis
RAD
+120 +60
+90
III II
aVF 5
Normal QRS axis
Age Mean (Range), degrees
1 wk - 1 mo +110 (+30 to +180)
1 - 3 mo +70 (+10 to +125)
3 mo - 3 yr +60 (+10 to +110)
More than 3 yr +60 (+20 to +120)
Teenage - adult +50 (-30 to +105)
 AXIS … clue to remember
Imaging the patient’s body
R = Right arm facing you
L = Left arm

aVR aVL

I no 1 = heart on left
side of patient’s body

Clock wise
rotation

III II
aVF

no 3 is after no 2 no 2 is after no 1
F = Faeces
7
 AXIS … how to remember?
Mostly error : wrong positioning of lead II & III

aVR aVL
FALSE
TRUE
aVR aVL

I I

III II

III II
aVF aVF 8
AXIS … positive Leads

 Lead I, Lead II, Lead III

 Lead aVR, Lead aVL, Lead aVF

aVR aVL

III II
aVF
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P WAVE
(gelombang atrium)
Normal:
Tinggi ≤ 2,5 mm
Durasi < 0,08 detik
P wave positif di I,II ; negatif
di aVR

Dilihat paling jelas di Lead II

QRS Kompleks
(gelombang ventrikel)
 Kompleks QRS
Biasanya dihitung di lead V1, V6
Secara umum: Normal < 0,1 detik ; Blok inkomplit 0,1-0,12; blok komplit >0,12
 Chest leads of normal Heart
Posterior

HORIZONTAL
HORIZONTAL
REFERENCE
REFERENCE SYSTEM
SYSTEM SPINE

VIEW
VIEW
FROM
FROM LV
CRANIAL
CRANIAL
Normal
V6
Heart RV

V5

V4
V1 V2 V3
Anterior

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Chest leads of RVH LV
V6
 High R in V1 & V2 RVH
V5
 Deep S in V5 & V6
V4
V1 V2 V3

in:
 ASD
 Pulmonal

stenosis (PS)
 ToF
 DORV

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 Chest leads of LVH
LVH

V6
RV
V5

V4
V1 V2 V3

 Deep S in V1 & V2
 High R in V5 & V6

in:
 VSD
 PDA
 Mitral regurgitation (MR) of RHD
 Aorta regurgitation (AR) of RHD

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 Biventricular hypertrophy
LVH
V6
RVH

V5

V1 V2 V3 V4

 TGA (Transposition of great

arteries)
 complete AVSD
(Atrioventricular septal
defect)
• Katz-Wachtel phenomenon: large equiphasic QRS complexes in ≥ 2 of
the limb leads and in the mid-precordial leads (i.e. V2 through V5),
with normal QRS duration

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 Normal amplitude of R wave
Mean (Upper limit), mm
Lead Age
0-1 mo 1-6 mo 6-12 mo 1-3 y 3-8 y 8-12 y 12-16 y Adult
I 4 (8) 7 (13) 8 (16) 8 (16) 7 (15) 7 (15) 6 (13) 6 (13)
II 6 (14) 13 (24) 13 (27) 12 (23) 13 (22) 14 (24) 14 (24) 5 (25)
III 8 (16) 9 (20) 9 (20) 9 (20) 9 (20) 9 (24) 9 (24) 6 (22)
aVR 3 (8) 2 (6) 2 (6) 2 (5) 2 (4) 1 (4) 1 (4) 1 (4)
aVL 2 (7) 4 (8) 5 (10) 5 (10) 3 (10) 3 (10) 3 (12) 3 (9)
aVF 7 (14) 10 (20) 10 (16) 8 (20) 10 (19) 10 (20) 11 (21) 5 (23)
V3R 10 (19) 6 (13) 6 (11) 6 (11) 5 (10) 3 (9) 3 (7)
V4R 6 (12) 5 (10) 4 (8) 4 (8) 3 (8) 3 (7) 3 (7)
V1 13 (24) 10 (19) 10 (20) 9 (18) 8 (16) 5 (12) 4 (10) 3 (14)
V2 18 (30) 20 (31) 22 (32) 19 (28) 15 (25) 12 (20) 10 (19) 6 (21)
V5 12 (23) 20 (33) 20 (31) 20 (32) 23 (38) 26 (39) 21 (35) 12 (33)
V6 5 (15) 13 (22) 13 (23) 13 (23) 15 (26) 17 (26) 14 (23) 10 (21)

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 Normal amplitude of S wave
Mean (Upper limit), mm
Lead Age
0-1 mo 1-6 mo 6-12 mo 1-3 y 3-8 y 8-12 y 12-16 y Adult
I 5 (10) 4 (9) 4 (9) 3 (8) 2 (8) 2 (8) 2 (8) 1 (6)
V3R 3 (12) 3 (10) 4 (10) 5 (12) 7 (15) 8 (18) 7 (16)
V4R 4 (9) 4 (12) 5 (12) 5 (12) 5 (14) 6 (20) 6 (20)
V1 7 (18) 5 (12) 7 (18) 8 (21) 11 (23) 12 (25) 11 (22) 10 (23)
V2 18 (33) 15 (26) 16 (29) 18 (30) 20 (33) 21 (36) 18 (33) 14 (36)
V5 9 (17) 7 (16) 6 (15) 5 (12) 4 (10) 3 (8) 3 (8)
V6 3 (10) 3 (9) 2 (7) 2 (7) 2 (5) 1 (4) 1 (4) 1 (13)

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 Normal R / S ratio
Mean, Lower limit, Upper limit
Lead Age
0-1 mo 1-6 mo 6-12 mo 1-3 y 3-8 y 8-12 y 12-16 y Adult
Lower 0.5 0.3 0.3 0.5 0.1 0.15 0.1 0.0
V1 Mean 1.5 1.5 1.2 0.8 0.65 0.5 0.3 0.3
Upper 19 S=0 6 2 2 1 1 1
Lower 0.3 0.3 0.3 0.3 0.05 0.1 0.1 0.1
V2 Mean 1 1.2 1 0.8 0.5 0.5 0.5 0.2
Upper 3 4 4 1.5 1.5 1.2 1.2 2.5
Lower 0.1 1.5 2 3 2.5 4 2.5 2.5
V6 Mean 2 4 6 20 20 20 10 9
Upper S=0 S=0 S=0 S=0 S=0 S=0 S=0 S=0

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Transitional zone
 Found at precordial lead
 Equiphasic QRS wave determine the position of ventricular septum
 Normal in V2-V3

LV
V6
RV

V5

V4
V1 V2 V3

27 PIT 7 Sby 1 Nov 2015

 Right
V1 V2 V3
V3 V2 V1 V4
V4
V6
Right V5
RVH

or
V5
V5
RVH RVH V6
V6
V4
V1 V2 V3

Right

Clockwise rotation of
Shift to left of Shift to left of Transitional zone
Transitional zone Transitional zone

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 LVH V1 V2 V3
Left V4
V3 V2 V1

or
V4 V5
V6 Left
V5 V6
V5
V6
V4
V1 V2 V3 LVH
Left LVH
Counter clockwise rotation
Shift to right of Shift to right of of Transitional zone
Transitional zone Transitional zone

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