Biventricular Enlargement/ Hypertrophy

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Milton Hunt
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1 Biventricular Enlargement/ Hypertrophy Keywords congenital heart disease left ventricular hypertrophy right ventricular hypertrophy SR MITTAL Abstract Electrocardiographic diagnosis of early biventricular hypertrophy is difficult because opposing forces of hypertrophy of two ventricles cancel each other In presence of voltage criteria of LVH, right axis deviation, clockwise rotation, signs of right atrial overload and R/s ratio greater than 1 in V 1 suggest biventricular hypertrophy Tall R with deep S in leads V 2 with combined amplitude greater than 60 mm (Katz Wachtel sign) also suggests biventricular hypertrophy This sign is common in children with ventricular septal defect and pulmonary artery hypertension These signs have high specificity but low sensitivity ECG diagnosis of early biventricular hypertrophy (BVH) is difficult because normally greater left ventricular forces require much greater degree of right ventricular hypertrophy, before it can manifest on ECG 1 This is because opposing forces of hypertrophy of two ventricles cancel each other 2 Further, intraventricular conduction defects, accompanying hypertrophy of either ventricle also affect electrocardiographic diagnosis of ventricular hypertrophy Several criteria are used for diagnosis of biventricular hypertrophy Common causes include - Mitral regurgitation with pulmonary artery hypertension This is common with rheumatic etiology - RVH from any cause with systemic hypertension/ gross aortic regurgitation/ mitral regurgitation - Cardiomyopathy (A) In the presence of voltage criteria of left ventricular hypertrophy (LVH), one or more of the following findings suggest BVH 3,4 Right axis deviation Clockwise rotation- shift in precordial transition zone to left (Figure 1) Deep S in V 5 Signs of right atrial overload Dr SR Mittal is Head, Department of Cardiology at Mittal Hospital and Research Centre, Ajmer, Rajasthan Cardiology Today VOL XXI NO 2,

(a) (b) (a) (b) Figure 2 Electrocardiogram showing prominent R wave in lead V 1, right atrial overload (tall peaked P waves in leads II, avf and V 1 ) with tall R waves in leads V 2 to Figure 1

lead V 1 ), clockwise rotation and prominent qr in leads V 4 and V 5 (Figure 2,3) Tall R in right precordial loads R/S ratio greater than 15 (Figure 1, 2,3) Caution- Asthenic individuals may have LVH

2 (a) (b) (a) (b) Figure 2 Electrocardiogram showing prominent R wave in lead V 1, right atrial overload (tall peaked P waves in leads II, avf and V 1 ) with tall R waves in leads V 2 to Figure 1 Electrocardiogram from a patient of VSD with pulmonary artery hypertension showing right axis deviation, prominent R wave in lead V 1, left atrial overload (prominent negative deflection of P wave in lead V 1 ), clockwise rotation and prominent qr in leads V 4 and V 5 (Figure 2,3) Tall R in right precordial loads R/S ratio greater than 15 (Figure 1, 2,3) Caution- Asthenic individuals may have LVH voltage criteria in absence of true LVH Emphysema and obesity may mask LVH voltage criteria Tall R with deep S in leads V 2 with combined amplitude greater than 60mm 3 (Figure 4, 5, 6) It is more likely to occur in children with ventricular-septal defect or AV- canal defect with pulmonary artery hypertension In these conditions, left ventricular volume overload is associated with right ventricular pressure overload Standard criteria have high specificity but low sensitivity 2 Most of the patients do not fulfil standard criteria because effects of enlargement of one ventricle cancel the effects of enlargement of another ventricle Several subtle ECG findings may also suggest early BVH Right axis deviation with qr configuration in V 5, (Figure 7) or - Predominant R in V 5 2 but not fulfilling LVH voltage criteria or Figure 3 Electrocardiogram from a patient of Tetralogy of Fallot with aortic regurgitation showing right axis deviation, right atrial overload (tall peaked P wave in leads V 1, V 2 ) with tall R waves in leads V 2 and V 4 Figure 4 Electrocardiogram from a case of Eisenmenger syndrome showing right axis deviation, prominent R in lead V 1, left atrial overload and tall RS (55 mm) in leads V 4 and V 5 (Katz-Wachtel sign) 86 Cardiology Today VOL XXI NO 2, 2017

Figure 5 Electrocardiogram from case of Ventricular septal defect (VSD) with pulmonary artery hypertension showing incomplete RBBB with tall RS (>60 mm) in leads V 3 to V 5 (Katz- Wachtel sign)

pulmonary artery hypertension showing SISIISIII, counter clockwise loop (q in I and avl), prominent R in lead V 1 with tall RS in lead V 3 (70 mm) and V 4 (80 mm) (Katz Wachtel sign) Figure 9

showing right axis deviation, prominent R in lead V 1 and qr in leads V 5 - RS in V 1 and very deep S in V 2 2,6 (Figure 8, 9) or - Prominent R with ST-depression in lead V 5 suggestive of LVH

3 Figure 5 Electrocardiogram from case of Ventricular septal defect (VSD) with pulmonary artery hypertension showing incomplete RBBB with tall RS (>60 mm) in leads V 3 to V 5 (Katz- Wachtel sign) Figure 8 Electrocardiogram showing atrial fibrillation, right axis deviation, deep S wave in leads V 3 (35 mm) and V 4 (35 mm) Figure 6 Electrocardiogram from a case of A-V canal defect with pulmonary artery hypertension showing SISIISIII, counter clockwise loop (q in I and avl), prominent R in lead V 1 with tall RS in lead V 3 (70 mm) and V 4 (80 mm) (Katz Wachtel sign) Figure 9 Electrocardiogram showing atrial fibrillation, qr in V 1 and deep S in leads V 3 (45mm) and V 4 (35 mm) Figure 7 Electrocardiogram from a case of VSD with right ventricular outflow tract obstruction showing right axis deviation, prominent R in lead V 1 and qr in leads V 5 - RS in V 1 and very deep S in V 2 2,6 (Figure 8, 9) or - Prominent R with ST-depression in lead V 5 suggestive of LVH (Figure 10) or - Left atrial enlargement 2 (Figure 11,12) (Except in mitral stenosis) Caution- Left inferoposterior hemiblock should not be wrongly interpreted as right axis deviation S 1 S 2 S 3 with prominent R or qr in V 5 Tall equiphasic RS in leads V 3 and V 4 not fulfilling criteria of 60 mm (Figure 13) Cardiology Today VOL XXI NO 2,

Tall R in right as well as left precordial leads 4 These criteria are less specific but more sensitive Figure 10 Electrocardiogram showing P-Pulmonale (tall peaked P waves in V 2, V 3 ), qr

of P wave in lead V 1 ) 1 Mirvis DM, Goldberger AL Electrocardiography In Mann DL, Zipes DP, Libby P, Bonow RO (eds) Braunwald s Heart Disease Elsevier, Philadelphia; 2015:114-152 2 De luna AB,

4 Tall R in right as well as left precordial leads 4 These criteria are less specific but more sensitive Figure 10 Electrocardiogram showing P-Pulmonale (tall peaked P waves in V 2, V 3 ), qr configuration in lead V 1 and V 2, and ST depression in leads V 4 - Figure 11 Electrocardiogram showing right axis deviation, incomplete RBBB and left atrial overload (prominent negative deflection of P wave in lead V 1 ) 1 Mirvis DM, Goldberger AL Electrocardiography In Mann DL, Zipes DP, Libby P, Bonow RO (eds) Braunwald s Heart Disease Elsevier, Philadelphia; 2015: De luna AB, Goldwasser D, Fiol M, Bayes- Genis A Surface electrocardiography In Fuster V, Walsh RA, Harrington RA(eds) Hurst s The Heart Mc Graw Hill, New York; 2011: Hancock EW, Deal BJ, Mirvis DM, Okin P, Kligfield P Gettes LS AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram Part V Electrocardiogram changes associated with cardiac chamber hypertrophy J Am Coll Cardiol 2009; 53: Mirvis DM, Goldberger AL Electrocardiography In Bonow RO, Mann DL, Zipes DP, Libby P(eds) Braunwald s Heart Disease Elsevier, St Louis; 2012: Schamroth C Right ventricular hypertrophy In Schamroth C(ed) An introduction to electrocardiography Blackwell Science, France; 1982: Wagner GS, Lim TH Chamber enlargement In Wagner GS(ed) Marriott s Practical electrocardiography Wolters Kluwer, Philadelphia; 2008:71-96 Figure 12 Electrocardiogram showing right axis deviation, biatrial enlargement (tall peaked P wave in leads II, III, avf, prominent negative P wave in leads V 1 to V 3 and wide and notched P wave in V 5 ) and qr in V 7 Figure 13 Electrocardiogram showing SISIISIII counter clockwise loop (q in I and avl), RVH (tall R in V 1 ), tall RS in V 3 and qrs in V 5 88 Cardiology Today VOL XXI NO 2, 2017

5 MCQs Biventricular enlargement /hypertrophy Q1 Which ECG findings suggest biventricular enlargement? Q4 In Katz-Wachtel phenomenon R + S amplitude should be more (A) LVH +LAD than (B) LVH + RAD (A) 30 mm (C) LVH + Clockwise rotation (B) 40 mm (D) LVH + Counter clockwise rotation (C) 50 mm (D) 60 mm Q2 Which ECG findings do not suggest biventricular enlargement? Q5 Katz- Wachtel phenomenon is (A) LVH + deep S in V 5 commonly seen in (B) LVH + Tall R in V 1 (A) VSD + PAH (C) LVH + left atrial overload (B) AV canal defect with PAH (D) LVH + right atrial overload (C) LV to RA shunt (D) TOF + AR Q3 Katz- Wachtel phenomenon is seen in (A) Leads V 3 R to V 1 (B) Leads V 2 (C) Leads V 7 to V 8 (D) Leads I and avl Q6 Which ECG finding are not suggestive of biventricular hypertrophy? (A) R in V 1 + qr in V 5 (B) R in V 1 + S in (C) R in V 1 + deep S in V 2 (D) RAD + left atrial overload Q7 Causes of right axis deviation - (A) RVH (B) Left postero-inferior fascicular block (C) Left antero-superior fascicular block (D) RBBB Q8 (A) (B) (C) (D) Causes of voltage criteria of LVH Asthenic individuals Emphysema Obesity Pericarditis Answers:(1) B, C, (2) A,C, (3)B, (4) D, (5) A, B, (6) B, (7) A, B, (8) A Cardiology Today VOL XXI NO 2,

Left posterior hemiblock (LPH)/

Left posterior hemiblock (LPH)/ ECG OF THE MONTH Left Postero-inferior Depolarization Delay Keywords Electrocardiography Intraventricular conduction delay, Inferoposterior hemiblock, Left posterior fascicular block, Left posterior hemiblock