Introduction

ECG
Phys exam
Chest X Valvular and congenital :
Ray
§ ECG changes are related with
heart chamber enlargement

Anamnesis Laboratorium § They are also rhythm disturbance

§ Chest X-ray is related to

chamber enlargement,
Five fingers distribution of vascular marking
diagnostic tools  congestion, blood flow to the
lung (pletora/oligemia)
ECG criteria of chamber enlargement
Right Atrial Left Atrial Enlargement

- Abnormal voltage of P wave (>2,5 - Wide P wave duration (>0,12 ms).

mV) normal duration. - P mitral
- Best seen in II,,V1
- Best seen in II,V1
- P Pulmonale
V1
V1

Left Ventricular
Right Ventricular
SV1 + RV5 or RV6 > 35 mm
-R/S ratio >1 in right precordial R waves in aVL 11-13 mm
-RAD Slight ST depression or T wave
- T wav e i nv e rs i o n i n r i g h t t o m i d inversion (strain type)
precordial lead. LAD
ECG criteria of chamber enlargement
q Ventricular hypertrophy vs dilatation no spesific ECG criteria to
differentiate

q Biatrial enlargement :
Presence of LAD and RAD criteria in same ECG
Broad and notched P wave in lead I,II, prominent negative component
in V1, initial force tall in lead II.
ECG criteria of chamber enlargement
q Biventricular enlargement
Presence of LVH and RVH in the same ECG.

LVH with RAE, RAD, tall bifasic

QRS in multiple lead, deep S
wave in V5-6
.
RVH with tall R wave and
deep S wave V2-5, QRS
amplitude > 50 mm

Katzh Wachel
phenomenon Large biphasic
QRS complexes tall R wave +
deep S waves
Chest X ray
Normal Chest
X ray
Mitral Regurgitation

RA RA LA RA LA
LA

RV LV RV LV RV LV

Aorta Aorta
Aorta

Pulmonary artery Pulmonary artery

Pulmonary artery
Mitral Regurgitation
ECG : LAE, LVH, in some extent RVH if pulmonary hypertension has
developed. Atrial Fibrillation often occur in chronic AF.
Mitral Regurgitation

Pulmonary
congestion

LA Enlargement

LV Enlargement
Mitral Stenosis

RA LA RA LA

RV LV RV LV

Aorta Aorta

Pulmonary artery Pulmonary artery

Mitral Stenosis
ECG : LAE (Slurred, wide P wave/P mitral),
RAD, RVH if pulmonary hypertension has developed. Atrial Fibrillation
is quite common
Mitral Stenosis

Pulmonary
congestion

LA Enlargement

RVH
Aortic Regurgitation

RA LA RA LA

RV LV RV LV

Aorta Aorta

Pulmonary artery Pulmonary artery

Aortic Regurgitation

ECG : LV enlargement to some extent LAE/LAH, LAD

Aortic Regurgitation

LA Enlargement

LV Enlargement
Aortic Stenosis

RA LA RA LA

RV LV RV LV

Aorta Aorta

Pulmonary artery Pulmonary artery

Aortic Stenosis
ECG : Left Ventricular Hypertrophy, LAD
Aortic Stenosis

Post stenotic
dilatation
q In valvular heart disease , ECG and Chest X-ray can give a clue when the
physical examination was in doubt.

q Galavardin murmur  mimicking MR  from ECG and chest X ray will

shows LVH and post stenotic dilatation.

q Austin Flint murmur  mimicking MS  ECG and chest X ray shows LV

enlargement.
Atrial Septal Defect

RA LA
RA LA

RV LV
RV LV

Aorta
Aorta
Pulmonary artery
Pulmonary artery
Atrial Septal Defect
RAE RVH

ASD ostium
secundum and sinus
venosus
Atrial Septal Defect

Plethora
PA enlargement

RVH
Ventricular Septal Defect
ECG and X ray findings are depend on size and pulmonary vascular resistance.

RA RA LA
LA

RV RV LV
LV

Aorta
Aorta

Pulmonary artery
Pulmonary artery
Low PVR High PVR

ECG. : LVH ECG. : BVH

LAH (+-) LAH
RVH
Ventricular Septal Defect
Ventricular Septal Defect

Plethora

LAH

BVH
Tetralogy of Fallot
Tetralogy of Fallot
RVH

Sudden transition RsrS

RAD in precordial
Tetralogy of Fallot
Patent Ductus Arteriosus

RA RA LA
LA
?
RV RV LV
LV

PDA

Aorta Aorta
Pulmonary artery Pulmonary artery
Patent Ductus Arteriosus

Plethora
Triple knuckle

Inverted coma
sign