ECG

ATRIAL SEPTAL DEFECT

The most frequent ECG abnormalities in ASD
are right bundle branch block (RBBB)
pattern or rsR' pattern in lead V1 .

In patients with large ASD, presence of tall R

or R' in lead V1 suggests development of
pulmonary hypertension .
 Afib, A flutter, SVT incidence increases in 4th
decade.
AV conduction defects
Sinus node dysfnction >> AV node dysfn
PR prolonged
HOLT ORAM syndrome PR prolongation, Sinus
brady, ectopic atrial rhythms
 Peaked P waves
Otium secundum ASD P wave axis is inferior
and to left. Upright P waves in leads 2,3,aVF
Superior venacava sinus venosus ASD, atrial
pacemaker is ectopic. P wave axis is leftward
and P waves inverted in leads 2,3,aVF. Upright
in aVL
Electrocardiogram from a 25-year-old woman with a superior vena caval sinus
venosus atrial septal defect. The P wave axis is leftward and markedly superior, so P
waves are inverted in leads 2, 3, and aVF; are isoelectric in lead 1; and are slightly
positive in lead aVR. The QRS pattern is typical of a left-to-right shunt at atrial level,
namely, a vertical QRS axis and prolonged terminal forces directed to the right,
superior and anterior, with an rSR prime in lead V1 and S waves in left precordial
leads
 QRS slightly prolonged. Duration increases
with age
Q waves in leads 2,3,aVF
Right axis deviation Infants with
symptomatic pulmonary hypertension/Young
females with pulmonary vascular disease
Left axis deviation rare. Acquired left
anterior fascicular block in adults
Electrocardiogram from a 5-year-old boy with a nonrestrictive ostium secundum atrial
septal defect and a 3.5 to 1 shunt. P waves are peaked and tall in lead 2 and V3R and in
leads V1-2. The QRS axis is vertical. Depolarization is clockwise, so Q waves appear in leads
2, 3, and aVF. There is an rsR prime pattern in leads V1 and V3R
 rSr prime or rsR prime in right precordial leads
Qwaves small/absent in left precordial leads
because shunt doesnt traverse left ventricle.
 Crochetage
Notch near apex of R waves in inferior leads of
ostium secundum and sinus venosus atrial
septal defects
rSr pattern + crochetage High specificity of
ASD
Ostium secundum ASD
Complete RBBB, RBBB pattern or rsR' pattern in lead V1.
Normal axis or right axis deviation due to right ventricular diastolic
overload.
Right atrial abnormality (may not be observed in children).

Prolongation of the PR interval: first degree atrioventricular block (less

frequent than ostium primum ASD).
Crochetage sign : notched R wave in inferior limb leads (may disappear
after closure of the defect).
If the defect is very large, severe atrial dilatation results in atrial flutter of
fibrillation in adults
In adult patients with ASD, closure of the defect does not decrease the
incidence of atrial fibrillation.
Ostium Primum ASD
rsR' pattern in lead (V1).
Left axis deviation (due to absence of the left anterior fascicle).
Left axis deviation persists even after closure of the defect.
Determination of QRS axis is very important in the differential
diagnosis of ostium secundum and ostium primum ASD.
Right axis deviation is not observed in ostium primum ASD.
Left atrial abnormality.
Complete or incomplete RBBB.
Prolongation of the PR interval (first degree atrioventricular
block).
Sinus venosus ASD
Right axis deviation.
Ectopic atrial rhythm may be observed.
Negative P waves in inferior leads (II, III and
aVF) suggest low atrial rhythm.
 ASD Algorythm

ASD

Counterclockwise
Clockwise loop
Loop

I ASD
II ASD
SV ASD LAD/Notching of s in
P -wave axis normal
P- wave axis superior inf leads
Crochetage+
Crochetage+ LVH/LAE
 VSD
The scalar tracing is influenced by the
size of the defect,
the size of the left-to-right shunt, and
the pulmonary vascular resistance
Restrictive VSD with normal pulmonary
artery pressure

normal electrocardiogram and an occasional rsr

prime pattern in lead V1.
+ septal aneurysm, there is an increase in the
incidence of rhythm and conduction
disturbances,especially atrial fibrillation, paroxysmal
atrial tachycardia, junctional rhythm, atrial flutter,
and complete heart block
Moderately restrictive ventricular septal defects
with a large left-to-right shunt

broad notched left atrial P waves in lead 1 and 2 and with a broad
deep P terminal force in lead V1
The QRS axis is normal although left axis deviation occurs in about 5% of
restrictive or moderately restrictive perimembranous defects
Inlet defects are associated with left axis deviation when they are a
component of an atrioventricular septal defect
In the presence of ventricular septal aneurysms, the incidence rate of left
axis deviation increases; it has been found in as many as 40% of patients
with multiple ventricular septal defects.
Volume overload of the left ventricle is reflected in tall R waves and tall
peaked T waves in leads 2, 3, and aVF and in prominent Q waves, tall R
waves, and tall peaked T waves in leads V5-6
Electrocardiogram from a 14-month-old
female with a moderately restrictive
perimembranous ventricular septal defect,,

A bifid left atrial P wave abnormality

is present in lead 1, and the P wave in lead
V1 has a deep broad terminal left artial
component.

The QRS axis is normal.

Deep Q waves, tall R waves, and upright T

waves in leads V5-6 are signs of left
ventricular volume overload
A nonrestrictive ventricular septal defect
with a large left-to-right shunt

exhibits right atrial or combined right and left atrial P wave

abnormalities, especially in lead 2 and in leads V1-2.
The QRS axis shifts moderately to the right.
Biventricular hypertrophy increased R wave amplitude in lead V1, the
deep Q waves, tall R waves, and tall peaked T waves in leads V5-6 and in
large equidiphasic RS complexes (the Katz-Wachtel pattern) in
midprecordial leads
Infants with a nonrestrictive ventricular septal defect and large left-to-
right shunts occasionally exhibit marked right axis deviation and pure or
relatively pure right ventricular hypertrophy, except for large
equidiphasic complexes in one or more midprecordial leads
Electrocardiogram from a 3-month-old
female with a nonrestrictive
perimembranous ventricular septal defect

Peaked right atrial P waves appear in leads 1,

2, and V1-4.

Right ventricular hypertrophy is

manifested by prominent R waves in right
precordial leads and prominent S waves in
left precordial leads.

Left ventricular volume overload is reflected

in the deep Q waves, welldeveloped R
waves, and tall peaked T waves in leads V5-6.

Combined ventricular hypertrophy is

represented by the large RS
complexes in leads V2-5.
In Eisenmengers syndrome,

P waves are often normal in younger patients and

moderately
peaked in older patients.
Right axis deviation is moderate
LeadV1 exhibits all monophasic Rwave that is
occasionally notched on its upstroke and followed
by a small s wave.
Prominent S waves appear in left precordial leads, but
combined ventricular hypertrophy is lacking
Electrocardiogram from a 19-year-
old man with a nonrestrictive
perimembranous ventricular septal
defect and Eisenmengers
syndrome.

The P waves are normal.

Right axis deviation is mild.

Right ventricular hypertrophy is

manifested by the tall monophasic
R wave in lead V1
 VSD

LEFT AXIS RAD

Counter clockwise-
Clockwise loop-
DORV
L-TGA Severe PAH
INLET VSD
MULTIPLE MUSCULAR
TRICUSPID ATRESIA
 VSD

LVH BVH

MODERATELY WITH RAE-

NONRESTRICTIVE
RESTRICTIVE GERBODES
 PDA
A moderately restrictive patent
ductus arteriosus with increased
pulmonary blood flow
prolonged bifid left atrial P wave in
one or more limb leads and in
right precordial
Atrial fibrillation occurs in older
patients.
The QRS axis is usually normal, but
an occasional infant has right axis
deviation, especially neonates with
respiratory distress
Prominent q waves and tall R waves of left
ventricular volume overload appear in leads
2, 3, and aVF. deep S wave in lead V1
prominent q waves, tall R waves, and peaked
upright T waves in leads V5-6.

Biventricular hypertrophy is reflected in the

large RS complexes in leads V2-4,
 A nonrestrictive patent ductus with low
pulmonary vascular resistance
biatrial P waves and combined ventricular
hypertrophy.
tall R waves and prominent S waves in leads
V5-6.
Volume overload of the left ventricle is
responsible for tall R waves, prominent q waves,
and tall peaked T waves in leads V5-6
 Patent ductus with pulmonary
vascular disease and reversed shunt
peaked right atrial P waves in leads 2, 3, and
Right ventricular hypertrophy is manifested by
right axis deviation, tall R waves in lead V1, and
inverted right precordial T waves and is
prominent in left precordial leads S waves
R waves in leads V5-6 imply that a left to-right
shunt previously existed
 TOF
P wave normal
PR interval normal
Rt axis deviation RVH
RVH Tall monophasic R wave in lead V1
abrupt change to rS in V2
 Pulmonary blood flow LV filling
Depth of Qwaves and amplitue of R waves in
leads V5-
 Balanced shunt small q waves and well
developed R waves in V5-6
Left to right shunt Deep left precordial Q
waves and tall R waves
Mildly cyanotic girl ecg

P waves normal

Rt axis deviatioon
Morophasic R wave in V1

prominent R waves in left precordial

leads
Adequately filled LV

Biphasic RS in V3,V4
Biventricular hypertropphy
well-developed R waves and
prominent Q waves in leads V5-6
indicate adequate filling of a
well-developed Left ventricle.