·Clinical
Electrocardiography
Cluldım
in

·Clunucal
Electrocar diography
in Chuldien

·Clmical
Electrocar drogi aply
in Children
GERTRUDE H B NICOLSON, MD
A ocrate in Cardiology Chief of Children & Cardiac Clinic
and Asistant Lusiting Phy ician to the Children s Service at
St. Lukes Hospital Instructor in Pediatrics at Columina
Unnersity Con ultant Cardiologit to Infants at Woman s
Ho pita! Con ultant New York Infirmary for Women and
Children Electrocardiographer of Bellevue llo pital from
1930 to 1931
TUF VACVILL IN COMPANY
Tele Jorh-1973

·Clmical
Electrocar drogi aphy
in Children
GERTRUDE H B NICOLSON, MD
A Octate in Cardiology Chief of Children Cardiac Clinic
and As istant Visiting Phy clan to the Childrens Service at
St. Lukes Hospital Instructor in Pediatrics a: Columbia
University Con ultant Cardiologit to Infants at Womans
Ho pita! Con ultant New York Infirmary for Women and
Children Electrocardiographer of Bellevue llo pital from
1930 to 1951
TUF MACHILLI COMPATI
Teie Jork-1973

·To ALEXANDER MCLEAN NICOLSON ·To ALEXANDER MCLEAN NICOLSON ·INTRODUCTION Although varying in detail according to the individual case the average child s electrocardiogram follows a simple pattern which may be recognized as that of a normal child rather through its lack of abnormal signs than by the presence of any definite form other than that by which it is characterized as belonging to the childhood group In the following pages illustrative electrocardiograms of average children are shown together with tracings frequently found in cer lain abnormal conditions It must be mentioned in this connection that the electrocardiogram may be of average form even in a badly damaged heart and it is to be remembered that the electrocardiogram is only an adjunct to a clinical examination The findings in this book are based on the study of electrocardiograms taken on 500 children from the wards and clinics of St Lukes Hospital New York City, and from private practice for the sake of uniformity the tracings have been taken with the child in a sitting or propped up position We have found that children do not (car the examination while in a sitting position as they often do when supire and again cardiacs in failure cannot le fiat during the test Infant and child sized electrodes were used for smaller children The tracings of 350 physically normal fourth year students t be ineen the ages of 22 and 26 years have been used as young adult tracings for comparison with this group The delections and intervals present in a normal cardiac cycle are considered individually and as a whole Normal vanations are noted and abnormal tracings are descnbed Characteristics found in each Cambridge instruments ha e been used 10 a 1 caminations + Department of Mec cibe Columbia Umiesty VIL ·INTRODUCTION Although varying in detail according to the individual case the average child s electrocardiogram follows a simple pattern which may be recognized as that of a normal child rather through its lack of abnormal signs than by the presence of any definite form other than that by which it is characterized as belonging to the childhood group In the following pages illustrative electrocardiograms of average children are shown together with tracings frequently found in cer lain abnormal conditions It must be mentioned in this connection that the electrocardiogram may be of average form even in a badly damaged heart and it is to be remembered that the electrocardiogram is only an adjunct to a clinical examination The findings in this book are based on the study of electrocardiograms* taken on 500 children from the wards and crucs of St Lukes Hospital New York City, and from private practice For the sake of uniformity the tracings have been taken with the child in a sitting or propped up position We have found that children do not ſcar the examination while in a sitting position as they often do when suprae and agam cardiacs in failure cannot lie flat during the test Infant and child sized electrodes were used for smaller children The tracings of 350 physically normal fourth year students t be fucen the ages of 22 and 26 years have been used as young adult tracings for comparison with this group The delections and intervals present in a normal cardiac cycle are considered individually and as a whole Normal vanations are noted and abnormal tracings are descnbed Characteristics found in each Cambridge instruments ha e beta used in a caminations + Department of Mec cine Columbia Umiss ty ·TABLE or CONTENTS v1 Preface Introduction VII Chapter 1 The Deflections and intervals of the Electrocard:ogram of the Child 16 II Heart Position Anatomic and Electrocardiographic III Bipolar and Unipolar Limb Leads IV Unipolar Precordial Leads 22 27 V The Childs Electrocardiogram in Disease 33 57 VI The Electrocardiogram in Congenital Heart Lesions VII Rate and Rhythms Appendix Bibliography Index 88 101 106 113 ·TABLE or CONTENTS Vi Preface VII Introduction Chapter 1 The Deflections and intervals of the Electrocardiogram of the Child II Heart Position Anatomic and Electrocardiographic 16 22 27 33 III Bipolar and Unipolar Limb Leads IV Unipolar Precordial Leads V The Childs Electrocardiogram in Disease VI The Electrocardiogram in Congenital Heart Lesions VII Rate and Rhythms Appendu Bibliography Index 57 88 101 106 113 IX ·CHAPTER 1 The Deflections and Interals of the Electrocardiogram of the Child The P deflection is the term given to the initial wave in the normal cardiac cycle which is the invasion or depolarızation wave of atrial musculature during which time the impulse passes from the sinoatrial to the atrioventricular node The time taken by the accession or in vasion of atral musculature is measured by the width of the P deAction At birth and in the first weeks of life the average duration of this event is 0056 second. The average pulse rate at this age is 164 per minute There is a definite increase in P width as the child frons older as noted by the following measurements From 2 to 12 months the rate of 143 from 2 yea 0078 second and the average rate is 112 and from 6 to 13 years the ume consumed is 008 second while the average rate 13 94 (Tables 1 and 7) In the young adult the average P width is 0 10 to 011 second The voltage or amplitude of the P Wave varies in each lead and is greatest in lead 2jiith an upper limit of 2 mm In unipolar leads P waves are on the average highest in V, and V The Phase is normally upnght in leads 1 and 2 although it may ·CHAPTER 1 The Deflections and Inten als of the Electrocardiogram of the Child The P deflection is the term given to the initial wave in the normal cardiac cycle which is the invasion or depolarization wave of atrial musculature during which time the impulse passes from the sinoatrial to the atrioventricular node The time taken by the accession or in vasion of anal musculature is measured by the width of the P dcflction At birth and in the first weeks of life the average duration of this event is 0056 second. The average pulse rate at this age is 164 per minute There is a definite increase in P width as the child grows older as noted by the following measurements From 2 to 12 months the rate of 143 from 2 yea 0078 second and the average rate is 112 and from 6 to 13 years the une consumed is 008 second while the average rate 13 94 (Tables i and 7) In the young adult the average P width is 0 10 to 011 second The voltage or amplitude of the P Wave varies in each lead and is greatest in lead 2jith an upper limit of 2 mm In unipolar leads P waves are on the average highest in V, and V The Phase is normally upnght in leads 1 and 2 although it may 1 ·3 THE ELECTROCARDIOGRAM OF THE CHILD may also be noted to a less marked degree in the tracings of the nuc live Theumatic child (Fig 20) P waves may be absent as in atrial fibrillation (Figs 21a 25a and b and 57A) The atrial T ware or wave of atnal tepolarization may be recog nized as a depression in the PR segment or it may fall after the QRS complet. The Ta ware is best seen in a v block of high de gree and is apt to be more notice able when P 15 high (Fig 56C 1 and ) The PR interral is the time taken for the impulse to pass from the 5 a node to the ventricular Tauscle The interval starts at the beginning of P and ends at the start of the Ror of the O wave if present It includes the time taken to depolarize the atrial muscle (P wave) plus the time in which the impulse $ delayed at the av node and ihe main bundle of His unul the onset of ventricular de polanzation (P R segment) The Interval varies with heart rate and body size being shorter in more rapid and small hearts As would culorventncular be erpected the inters al is shorter ment Terent to contraction in the infant than in the young child and in the child than in the Fig. Diagram showing encals of the Cardiac cyc! by standard limb Jovag adult The average time of lead and sourd wa c cardiograns the PR internal in the 1 to Vertical squares = 1 my Horizontal Squart=004 second 8 week-old infants 0 107 second with an average rate of 16+ per minute in the 2 to 12 month-old baby 0 116 second with a rate of 143 and in the 1 to 6-year-old child it is 0 130 second with an antrage rate of 110 5 In the oider youngster of 6 to 13 years 0 152 ·3 THE ELECTROCARDIOGRAM OF THE CHILD may also be noted to a less marked degree in the tracings of the indc live theumatic child (Fig 20) P waves may be absent as in atrial fibrillation (Figs 21a 25a and b and 57A) The atrial T scare or wave of atnal tepolarization may be recog nized as a depression in the P R segment or it may fall after the QRS complet. The Ta wave is best seen in a v bloci of high de gree and is apt to be more notice able when P is high (Fig 56C 1 and The PR inlerral is the time talen for the impulse to pass from the sa node to the ventricular muscle The internal starts at the beginning of P and ends at the start of the Ror of the wave if present It includes the time taken to depolarıze the atnal muscle (P wave) plus the time in which the impulse is delayed at the av node and ihe main bundle of His unti the onset of ventricular de polanization R segment) The Interval varies with heart rate and body size being shorter in more rapid and small hearts As would Au scular Ventacular Dostale be expected the interval is shorter rent Tree 1o. fcontractor YCLE in the infant than in the young child and in the child than in the Diagram stowing encals of the cardiac cycl by standard lumb jovng adult The average time of lead and sound wac cardiograms Vertical squares = 1 my Horizontal the PR inien al in the 1 10 squarey = 001 second 8 week-old infantis 0 107 second with an average rate of 164 per minute in the 2 to 12 month-old baby 0:16 second with a rate of 143 and in the 1 to 6-year-old child it is 0 130 second with an ancrage rate of 110 5 Ja the oider youngster of 6 to 13 years 0 152 CARO: Fre!

·THE ELECTROCARDIOGRAM OF THE CHID 5 the standard limb leads of the nomal chuid but moderate nght of left axts deviation is not uncommon depending upon the rotation or position of the heart in the chest (Fig 71 Variation of deviation daztag helt tilation there is an ictezse ta tbe ve of the R deflecuon in these leads Paliect referred by Ds Rum Cudmote ) may appear in the same child with chance in the heart position as seer during duep held inspiration or expust01 (Figs 2 and 3) If a ch 18 has a vertical hear a nuht ani dev at 07 kith deep S and tall R: is the rule Il the heart is horizontally placed as it children with ·THE ELECTROCARDIOGRAM OF THE CHILD 5 the standard limb leads of the nomal chuid but moderate night or left axts deviation is not uncommon depending upon the rotation or position of the heart is the chest (Fig 7) Variation of deviation daag helt 1pitation there is an Istese a tbe ve of the K deflecnon in these leads Palieot relected by Dy Ruth Cudmote ) may appert in the sume child with chance in the heart position as seen during dep held inspiration or expiration (Figs 2 and 3) If a child has a kertical heart a nuht atis dev at 07 with deep S and tall R; is the rule ll the heart i honzontally placed as a children with ·# wa kuku SSL center wie w Mensen ܕܝܐ 1 A 1 -11,18% i en tidl. 7 ; ورزم 1 17 Tamang ang H ? 1 11 bigo Not 1 (15 1 en If It FFT! + it was usinalintekenbait Leusdece nu :: I turk 2 13 3 1 oplo 1: 1: +1 $ + alge valore ET more Fig 4 Electrocardiogram talen on 3 week old premature boy The voltage is low The heart rate is IKU There is slight cleration of the RT segment in lead 2 7 ·سال بمسعد ومحمد سعد منه لم يعدهنده بهم Les hisismicinions ! 1 l m + WA 1 3 . 7 H 2 2 7 **r*,* ter*, **::*** 1997 srirodi na 3 * Jusuissahiiii'uuise Leadus nu Limited 1 + 1 3 pri 73 2179 TE A ܐ ܐܨܕܪܵ܃ * 1 $ 3 FIG 4 Electrocardiogram taken on 3 week old premature boy The voltage is low The heart rate is 16U There is slight cleration of the RT segment in lead 2 7 ·THE ELECTROCARDIOGRAY OF THE CHILD 9 Qor R to its end R or S The average of 0065 in the child is shorter than that in the young adult in whom the upper limut is 010 and occasionally oil second The QRS interval is usually shortest der V, where the electrode is seasest the heart The time varies with age body size and build and heart rate beng **? -Watt hond. " 4. Fig 53 Market low voitage in 17 year-old girl with untreated hypo throuve Note inversion of T *38 Soi aus 1 and 2 slow heart rate and sluggish a y conduction D For compari on sunilar low rokage present 10 a 12 year-old girl with constri love pericarditis The rape rate is ine di linguisting 1c wrc Vemrular prematute conCI/Ons prenan leads ? and 3 asc coincidental greater in heavier hearts and shorer in infancy in small hears and in those with rapid rates The interal is commonly increased where there is a fibrosis of heart muscl. in cases where a bundle branch is blockcd and in richt ind left ventricular buperisophy it may be transiently pro longed in acute inlections as in acut rhumatic fever and during certain therapeutic procedures as under quinidinization in the Wolf Parkinson White syndrome the interval is leng rened The I vore is the term gyen to the instal downward or negative deflection of the depolarization complex of sentricular musculature and is due to an lul potential difference directed an,2} from the clentsodi in the normal child Q 13165 shen presentare larger than they ·9 THE ELECTROCARDIOGRAY OF THE CHILD Q or R to its end R or S The average of 0065 in the child is shorter than that in the young adult in whom the upper limutis 010 and occasionally Oil second The QRS interval is usually shortest over V, where the electrode is nearest the heart The time varies with age body size and build and heart rate bong * ww/, WA " YM Fig 32 Market low voltage in 17 year old girl with untreated hypow thyroidism Note inversion of T 38 Soi aus 1 and 2 slow heart rate and sluggish a y conduction For compari on similar low Sorage present in a 12 year old girl with consin live per caratus Therapy rate is the dutinguishing 1c wure Venrelax prematute con 2015 pret an icads ? ans 3 ase coincidental greater in heavier hearts and shorter in infancy in small hearts and in those with rapid rates The interval is commonly increased where there is a fibrosis of heart musch, in cases where a bundle branch is blocked and in richt ind left ventricular bypertrophy it may be transiently prolonged in acute inlections as in acut raumatic fever and during certain therapeutic procedures is under quinidization in the Wolf Parkinson White syndrome the interval is leng rented The wore is the term given to the initial downward or negative deflection of the depolarization complex of ventricular musculature and is due to an un potential difference directed 21,2} from the clentsodi in the normal child Q 13165 when present are farger than they ·11 THE ELECTROCARDIOGRAM OF THE CHILD muscle last to be activated such as the lateral and postenor basal wall of the left ventricie and are absent in tracings taken over muscle initially invaded or first to be activated as found over the night precordium The childs Q wave is usually absent over V, and V and 15 deepest on leads 3 and Ve It is normally narrow with an average width of 00175 second and depth of 0036 mm with a maximum of 75 mm O waves are frequently seen in lead 1 and in precordial leads facing the left ventrcie in left ventricular hypertrophy They are common in lead 3 and precordial leads over the right ventricle in nght ventricular hypertrophy In left bundle branch block Q waves are absent in tracings with . the electrode facing the left precordium a distinguishing point from those of left ventricular hypertrophy Abnormal 0 deflections are usually wide and greater than 25 per cent of the highest B deflection in the l ad The QT interrol starts at the beginning of Q and terminates at the end of T It includes the time taken by the impulse to invade the ventricular muscle and the time for the complete return of the muscle to its resting or polarized state The interval varies with heart rate sex and age It vanes also with the clectrolyte and water balance of the blood as with potassium loss and sodium retention with calcium and phosphorus changes or disturbances of carbohydrate metabolism androgenic and other factors The interval is incr-ased in heart failure in myocarditis and 15 ventricular hypertrophy dunng toxic states in quinidine in toucauon and is avitaminosis as well as in hypopotassema and hypocalcemia It is shortened in hypercalcemia and with digitalis cflect and occasionally in acute pericardius The lability of the intes val owing to its response to such external factors makes it unreliable as a constant measure of precision However although it is prolonged in most infectious diseases including theumatic fever it is useful ia determining the presenca of activity in questionable rheumatic infec tion when serial tracings are made (Figs 17A B, and C) The average measured QT peal together with its related 21 crage R R cycle may be converted to a unform standard through ·11 THE ELECTROCARDIOGRAM OF THE CHILD muscle last to be activated such as the lateral and postenor basal wall of the left ventricle and are absent in tracings taken over muscle initially invaded or first to be activated as found over the night precordium The child s Q wave is usually absent over V, and V and 35 deepest it leads 3 and Ve It is normally narrow with an average width of 00175 second and depth of 0036 mm with a maximum of 75 mm Quaves are frequently seen in lead 1 and in precordial leads facing the left ventricle in left ventricular hypertrophy They are common in lead 3 and precordial leads over the right ventricle in nght sentricular hypertrophy In left bundle branch block Q waves are absent in tracings with . the electrode facing the left precordium a distinguishing point from those of left ventricular hypertrophy Abnormal Q deflections are usually wide and greater than 25 per cent of the highest B deflection in the 1 ad The QT interral starts at the beginning of Q and terminates at the end of T It includes the time taken by the impulse to invade the ventricular muscle and the time for the complete return of the muscle to its resting or polarized state The interval varies with heart rate sex and age li vanes also with the electrolyte and water balance of the blood as with potassium loss and sodium retention with calcium and phosphorus changes or disturbances of carbohydrate metabolism androgenic and other factors The interval is incr-ased in heart failure in myocardius and 15 ventncular hypertrophy duning 1oxic states in quinudine in toucation and in avitaminosis as well as hypopoiassemia and hypocalcemia It is shortened in hypercalcemia and with digitalis cílect and occasionally in acute pericardius The lability of the inter val owing to its response to such extemal factors makes it unreliable as a constant measure of precision However although it is prolonged In most infectious diseases including Theumatic fever it is useful ia determining the presencn of activity in questionable theumatic infcc tion when serial tracings are made (Figs 17A B, and C) The average measured QT interal together with its related 21 crage R R cycle may be converted to a unform standard through ·13 THE ELECTROCARDIOGRAM OF THE CHILD its peak is shorter in leads from the right precordium than in hose taken over the left precordium of the normal child There is - sught increase in this time interval or delay in the intrinsicold eflections as the chud groxs older but the relative ratio of night Lo left continues (Table 4) The peak of R divides the QRS Reflections due to muscle activated before from that depolarized after the impulse reaches the fpuscle under the explonng electrode There may be two upward waves in the ORS complex separated by a gownward deflection The second wave R1, is often seen when the Clectrode is over the base of the heart from late activaton of the conus I slurring is present in the highest R neat its apex abnormal conduction is probable The wave is commonly extremely high in congenital heart disease (Fig 13a) A lare R peak in V, with early intrinsicold detection in Vo is seen in right sentricular hypertrophy and right bundle branch block (Figs 13a and 46) S rare is the designation of the final downward wave of the depolarization complex of ventncular muscle owing to negative cavity potentials being transmitted through a completely depolarized wall to the electrode over its epicardial surface The average depth of the S defection in the standard limb leads of childhood is 1 61 mm and over precordial leads 666 mm It is deepest in leads 2 and V and in the lounger age group It is often absent in the child and may vary in depth in 1 3 during respiration (Figs 2 and 3) Swaves are deepest in tracings from that portion of the wall where activation is completed first as is usual in unipolar leads taken with the terminal over the nght ventricle and absent where it is com pleted last as over the left ventricle The junction or l’es the term used for the meeting point of the QRS complet with the ST segment The ST segment is represented by the duration of time between the end of the S wave and the start of the T deflection It is the interval of time between the completion of depolarization and beginning of repolanzaron of sentncular musculature This segment varies according to the heart rate being longer a slow rates and shorter when the rate is rapid. The average duration of the S-T ·13 THE ELECTROCARDIOGRAM OF THE CHILD to its peak is shorter un leads from the right precordium than in those taken over the left precordium of the normal child There is a slight increase in this time interval or delay in the intrinsicold deflections as the child grows older but the relative ratio of night to left contumes (Table 4} The peak of R divides the QRS deflections due to muscle activated before from that depolarized after the impulse reaches the fpuscle under the explonng electrode There may be two upward waves in the ORS complex separated by a gownward deflection The second wave R1, is often seen when the clectrode is over the base of the heart from late activaton of the conus I slurring is present in the highest R neat its apex abnormal conduction is probable The wave is commonly extremely high in congenital heart disease (Fig 13a) A late R peak in V, with earlv intrinsicoid deflection in Ve is seen in right ventricular hypertrophy and right bundle branch block (Figs 13a and 46) S trare is the designation of the final downward wave of the depolarisation complex of ventncular muscle owing to negalie cavity potentials being transmitted through a completelv depolarized wall 10 the electrode over its epicardial surface The average depth of the S dilection in the standard limb leads of childhood is 1 61 mm and over precordial leads 666 mm It is deepest in leads 2 and V and in the younger age group It is often absent in the child and may vary in depth in 1 3 during respiration (Figs 2 and 3) Swaves are deepest in tracings from that portion of the wall where acuvation is completed first as is usual in unipolar leads taken with the terminal over the night ventricle and absent where it is com pleted last as over the left ventricle The junction or ' is the term used for the meeting point of the QRS complet with the S-T segment The ST segment is represented by the duration of time between the end of the S wave and the start of the T deflection It is the interval of time between the completion of depolarization and beginning of repolarization of sentacular musculature This segment varies according to the heart rate being longer in slow rates and shorter when the rate is sapid. The average duration of the S-T ·THE ELECTROCARDIOGRAM OF THE CHILD 15 is also opposite to that of the I deflection T Wave changes from involvement of epicardial and endocardial senincular surfaces may best be seen in unipolar limb leads Ureare is the term given to the positive after potential of muscle contraction It starts at the end of the T wase and is usually not visible in the child s tracing However in slow shythms and in the presence of hy popotassemia it may occasionally be fairly prominent (Figs $3c and 55C) ·THE ELECTROCARDIOGRAM OF THE CHILD 15 is also opposite to that of the T deflection T wale changes from involvement of epicardial and endocardial senincular surfaces may best be seen in unipolar limb leads Utcare is the term given to the positive after potential of muscle contraction It starts at the end of the T ware and is usually not visible in the child s tracing However in slow Thythms and in the presence of hy popotassemia it may occasionally be fairly prominent (Figs 53c and 55C) ·TRE ELECTROCARDIOGRAM OF THE CHILD 15 is also opposite to that of the T deflection T wave changes from ?110lvement of epicardial and endocardial ventricular surfaces may best be seen in vpipolar limb leads Oware is the tem guen to the positive after potenual of muscle contraction It starts at the end of the T wave and is usually not visible in the child s truung However in slow rhythms and in the presence of hypopotassemia it may occasionally be fairly prominent (Figs 53c and 55C) ·THE ELECTROCARDIOGRAM OF THE CHILD 15 is also opposite to that of the T deflection T wave changes from 2010lement of epicardial and endocardial ventricular surfaces may best be seen in vpipolar limb leads Ovare is the tem gnen to the positive after potential of muscle contraction It starts at the end of the T wave and is usually not visible in the child s trawing However in slow rhythms and in the presence of hypopotassemia it may occasionally be fairly prominent (Figs 53c and 55C)

·HEART POSITIOV AVATOVIC ELECTROCARDIOGRAPHIC
17
more horizontal position The electrocardiographic position of the
heart may also be horizontal and left electrical axis deviation is
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·17
HEART POSITIOV AVATOVIC ELECTROCARDIOGRAPHIC
more horizontal position The electrocardiographic position of the
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Standard and unipolar limb leads of children with average pre
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I 11 year-old girl
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·19 HEART POSITION ANATOMIC ELECTROCARDIOGRAPHIC deviation may depend on a mechanical shift in the relationship of the tuo ventricles to the chest or it may be due to disease or mal formation in which hypertrophy of either ventricle is commonly present The electrocardiogram of the normal child is peculiar to that child Apart from the changes consistent with growth and from those vana tions seen in the axis deviation of the entricular curves on rotation of the heart around its longitudinal axis the general characteristics present in a normal child s electrocardiogram are retained throughout childhood years with remarkable constancy Such differentiating points appearing to be inherent qualities of the individuals cardiac activity are inverted or diphasic P waves in leads 2 or 3 the presence of U saves the slurring or splitung of QRS compl xes the ongin of the S-T segments and the ratio of the voltage of LI to L3 Many of these signs are due to the consututional type of the in dividual child, and they may be found in several members of one family Similarities in the tracings of siblings are often so striking that differentiation of the electrocardiograms is rendered dificult as in the records of the siblings illustrated (Figs & and 10) In Fig 9 the tracings of two chudres a brother and sister are compared A resemblance is again present and shows low voltage of lead 1 in both and a diphasic T3 in one and inverted T3 in the other Higher P wave amplitude is present in the girl and greater T wave voltage in the boy as is usually seca in comparison between the sexes Thu P xase of atrial actsysty is grates in height in the standard limb leads of girls between the ages of 6 and 12 years than it is in boys of that age group The components of the QRST group of the standard limb leads are of greater amplitude in boys than in girls in the 6-10-12 age group (Fig 9) In this connection it is of interest to note that Benele in 1910 observed in his studies on the anatomy of the heart that the relatise volume of the atria to the ventncies *25 greater in the female that in the male At 12 years of age all standard limb Icad deflections are on the alerare greater in amplitude in boys than in gris The average heart rate in girls of 6 years and under and of 12 years and over ·19 HEART POSITION ANATOMIC ELECTROCARDIOGRAPHIC deviation may depend on a mechanical shift in the relationship of the two ventricles to the chest or it may be due to disease or mal formation in which hypertrophy of either ventricle is commonly present The electrocardiogram of the normal child is peculiar to that child Apart from the changes consistent with growth and from those vana trons seen in the axis deviation of the ventricular curves on rotation of the heart around its longitudinal axis the general characteristics present in a normal child s electrocardiogram are retained throughout childhood years with retnarkable constancy Such differentiating points appearing to be inherent qualities of the individuals cardiac activity are inverted or diphasic P waves in leads 2 or 3 the presence of U Waves the slurring or splitung of QRS compl xes the ongin of the S-T segments and the ratio of the voltage of LI to L3 Many of these signs are due to the consututional type of the in dividual child, and they may be found in several members of one family Similarities in the tracings of siblings are often so striking that differentiation of the electrocardiograms is rendered difficult as in the records of the siblings illustrated (Figs & and 10) In Fig 9 the tracings of two childres a brother and sister are compared A resemblance is again present and shows low voltage of lead 1 in both and a diphasic T3 in one and inverted T3 in the other Higher P Have amplitude is present in the girl and greater T xave voltage in the boy as is usually seen in comparison between the sexes Thu Psale of atrial actsvity is grates in height in the standard bmb leads of girls between the ages of 6 and 12 years than it is in boys of that age group The components of the QRST group of the standard limb leads are of greater amplitude in boys than in girls in the 6-to-12 age group (Fig 9) In this connection it is of interest to note that Beneke in 1910 observed in his studies on the anatomy of the heart that the relatise volume of the atria to the ventncies **s greater in the female than in the male At 12 years of age all standard limb lead deflections are on the 21erace greater in amplitude in boys than 10 girls The average heart rate in girls of 6 years and under and of 12 years and over ·HEART POSITION ANATOMIC ELECTROCARDIOGRAPHIC 21 Sinus arrhythmia is less frequently seen a boys than in girls where it is common between the ages of 7 and 12 years The monocardiogram of vann, or recforcardiogram of Wilton, gives an interesting insight into the relationship between the "Y-----!----- Fig 10 Tracing shortat leads 2 (tom two brothers (A and 8) 5 and 7 years old who had congenual heart lesions. Incomplete a block is present in both boys standard Icad electrocardiogram and the changing electrcal field of the heart For this study a record is made in the form of a loop by the function of the apices of several instantaneous axes which are deter mined from the fracoss Of Swo or three simultaneous Standard leads and nold at consecuine periods Although time-consuming with pres nt methods the vectorcardiogram promises to be a valuable asset espxcially in the study of congenital heart lessons ·21 HEART POSITION ANATOWC ELFCTROCARDIOGRAPHIC Sinus arrhythmia is less frequently seen ia bous than in girls where it is common between the ages of 7 and 12 years The monocarilogram of kann, or recforcardiocram of Wilton, gives an interesting insight into the relationship between the T1- Fig 10 Tracing thokay leads Z (tom tha brothers (A and A) 5 and 7 years old who had congengal beart lesions. Incomplete a v block is present in both boys standard icad electrocardiogram and the changing electncal field of the heart For this study a record is made in the form of a loop by the function of the apices of several tastantaneous axes which are detes mined from the tr3cOSS OS wo or three simultaneous standard leads and old af consecuine periods Afthough time-consuming with pres mt methods the vectorcardiogram promises to be a valuable asset espcially in the study of congenital heart lessons ·23 BIPOLAR AND UNIPOLAR I IMB LEADS Standard lead 2 Electrodes are placed on the right arm and left leg so that potential variations from the nght arm and left leg roots are noted in the tracing (When considering simultaneous points of the curves in different leads lead 2 equals the sum of leads 1 and 3 for all pracucal purposes ) P Waves are usually upnght and greatest in this lead They may show a slurring on the upstroke ard rarely they may be inverted as a positional effect Q waves are Oftens absent but they may be deep R waves are usually tall When present S deflections are often deepest in lead 2 T waves also reach their greatest standard lead height in this lead very rarely they may be inyerted because of heart position Standard lead 3 With electrodes placed on the left arm and left 1 & potential variations from the left arm and left leg roots are registered in the tracing P waves are inverted in lead 3 in about 10 per cent of normal childrent Upright R waves usually dominate the QRS complex in the normal child in this lead however in a horizontal electrocardiographic position left axis deviation with deep S or QS waves may be seen Q and S waves are often deep and may disappear or vary with position T waves are inverted in lead 3 in about 35 per cent of normal children In contrast to these bipolar leads unupolar leads record potentials Tront one extremely only the exploring electrode the other the in different electrode being at the so-called zero potential As the de Lections in unipolar limb leads are small augmented unipolar lumb kads as introduced by Goldberger are almost universally uscd These are designated as a V. a V and a Vp leads Unipolar leads arc valuable as a means of comparison between the night and left ventricles The electrocardiographic curve varies according to the portion of the heart that faces the limb root on which the electrode is placed This may be roughly either the great onfices of the heart or the night or left ventn le In the normal heart a relationship exists Beneco standard and unipolar limb leads so that if L1 resembles L2 VR is similar but invented and it L3 is the inverse of LI VL resembles Ll also if L2 and Li are similar F is also similar Again VI - VR=LI V-VR=12 VF - VL = 23 (Fig 7) IR the unipolar nght arm lead or as is more commonly used ·23 BIPOLAR AND UNIPOLAR I IMB LEADS Standard lead 2 Electrodes are placed on the sight arm and left leg so that potential variations from the nght arm and left leg roots are noted in the tracing (When considering simultaneous points of the curves in different leads lead 2 equals the sum of leads 1 and 3 for all pracucal purposes ) P Waves are usually upnght and greatest in this lead They may show a slurring on the upstroke ard rarely they may be inverted as a positional effect Q waves are often absent but they may be deep R waves are usually tall When present s deflections are often deepest in lead 2 T waves also reach therr greatest standard lead height in this lead very rarely they may be inserted because of heart position Standard lead 3 With electrodes placed on the left arm and left 1 g potential variations from the left arm and left leg roots are registered in the tracing P waves are inverted in lead 3 in about 10 fer cent of normal childrert Upright R waves usually dominate the QRS complex in the normal child in this lead however in a horizontal electrocardiographic position left axis deviation with deep S or QS waves may be seen Q and S waves are often deep and may disappear or vary with position T waves are inverted in lead 3 in about 35 pur cent of normal children In contrast to these bipolar leads unipolar leads record potentials from one extremity only the exploring electrode the other the in different electrode being at the so-called zero potential As the de fections in unipolar limb leads are small augmented unipolar lumb kads as introduced by Goldberger are almost universally uscd These are designated as a Va aV, and aVp leads Unipolar leads are valuable as a means of comparison between the nght and left ventricles The electrocardiographic curve varies according to the portion of the heart that faces the limb root on which the electrode is placed This may be roughly either the great onfices of the heart or the right or left ventn le In the normal heart a relationship exists between standard and unipolar limb leads so that if L1 resembles L2 VR is similar but inverted 200 i 23 18 the inverse of LI VL resembles Ll also of L2 and L3 are similar F is also similar Again VI - VRELI V-VR=L2 VF - VL=L3 (Fig 7) IR the unipolar nght arm lead or as is more commonly used ·BIPOLAR AND UNIPOLAR LNB LEALS 25 but may be diphasic or rarely inverted The usual QRS complex in the VL, lead of a child consists of an RS curve often of low voltage However the form depends on the electrical position of the heart and It is occasionally difficult to determine whether the base of the heart or the epicardial surface contributes more to the form of the QRS complex in this lead If the electrocardiographic position is verlica; the left arm root will face the clockwise rotated nght ventricle and the tracing will show an is complex and inverted T Kave If in a horizontal electrocardiographic position the left shoulder will face the counterclockwise rotated left ventricle and a QR will be inscribed and the P and T waves may be inserted when they will also be so in VR leads The semivertical electrocardiographic position shows low voltage of QRS IN VL. and the semihorizontal electrocardiographic position gives low voltage in VF The S-T segment, which is usually isoclectric is occasionally elevated or depressed (Fig 7) IF, the unipolar left leg lead or av, the auginented umpolar left leg lead shows the potential vanations of the left leg of left hip joint simular to those of the surface of the diaphragm facing the heart P wases are usually upright in VF leads The form of QRS in the childs VF lead depends upon the electrical position and rotation of the heart in the verucal electrocardiographic position VF is similar to leads over the left ventricle and will show Rs or qRs ventriculas compl xes xith high R waves in the honzontal electrocardiographic position the QRS form in VF resembles those over the night ventricle showing deep S Hales which mas disappear on deep inspiration (Fie 2) When the heart is in the semihorizontal position the QRS completes in VF are small When there is forward rotation of the apex the left leg lead will face the epicardial surface of the left ventricle and a qR will be seen in VF and when there is backward rota 11on an tS or Rs w be present reflecting potentials from the right ventricle Q waves in VF may be seen in normal tracings They are usuilly followed by tall R waves Rith a late peal A broad Q with smail nastow R IS abnormal as is true also when it is not accompanied by a QR in VR Rarely T rates may be inverted normally in VF but they are usually positive in this lead ·23 BIPOLAR AND UNIPOLAR LIVB LEALS but may be diphasic or rarely inverted The usual QRS complex in the VL, lead of a child consists of an RS curve often of low voltage However the form depends on the electrical position of the heart and it is occasionally difficult to determine whether the base of the heart or the epicardial surface contributes more to the form of the QRS complex in this lead If the electrocardiographic position is vertical the left arm root will face the clockwise rotated nght ventricle and the tracing will show an IS complex and inverted T Wave If in a horizontal electrocardiographic position the left shoulder will face the counterclockwise rotated left ventricle and a QR will be inscrbed and the P and T waves may be inverted when they will also be so in VR leads The semivertical electrocardiographic position shows low voltage of QRS IN VL and the semihorizontal electrocardiographic position gives low voltage in VF The S-T segment, which is usually isoclectric is occasionally elevated or depressed (Fig 7) IF, the unipolar left leg lead or aV, the auginented unipolar left leg lead shows the potential vanations of the left leg or left hip joint similar to those of the surface of the diaphragm facing the heart P wases are usually upright in VF leads The form of QRS in the childs VF lead depends upon the electrical position and rotation of the heart in the vertical electrocardiographic position VF is similar to leads over the left ventricle and will show Rs or qRs ventricular compl xes with high R waves In the honzontal electrocardiographic Position the QRS form in VF resembles those over the nght ventricle showing deep 5 Haies which mas disappear on deep 2putation (Fie 2) When the heart is in the semihorizontal position the QRS completes in VF are small When there is forward rotation of the apex the left leg lead will face the epicardial surface of the left ventricle and a QR will be seen in VF and when there is backward rota 110ft an tS or Rs will be present reflecting potentials from the right Tentsile Q waves in VF may be seen in normal tracings They are usually followed by tall R waves rith a late peal A broad with small DISTOW R is abnormal as is true also when it is not accompanied by a QR in VR Rarely T wales may be inverted normally in VE but they are usually positive in this lead ·CITAPTER IV Unipolar Precordial Leads Precordial Unipolar Learls According to the criteria of the New York Heart Association precordial leads are taken on the chest at desired points over a line extending from the right sternal margin at the level of the fourth intercostal space to the junction of the left midclavicular line with the fifth intercostal space continuing at this level around the left chest Right-chest leads are taken over the right chest in a similar manner (Fig 11A and B) B Positions of unipolar precordial leads shown by pennies on chest of 6 year-old asthmatic girl A. Posterior anterior yiew B Left anterior oblique KW (After Hecht) 27 ·CIIAPTER IV Unipolar Precordial Leads Precordial Unipolar Leads According to the criteria of the New York Heart Association precordial leads are taken on the chest at desired points over a line extending from the night sternal margin at the level of the fourth intercostal space to the junction of the left midclavicular line with the fifth intercostal space continuing at this level around the left chest Right-chest leads are taken over the right chest in a similar manner (Fig 11A and B) B Fig 12 Positions of unipolar precordial leads shown by pennies on chest of 6 ycar-old asthmatic girl A Posterior anterior yiew B Left anterior oblique KW (After Hecht) 27 ·CHAPTER IV Unipolar Precordial Leads Precordent Unipolar leads According to the criteria of the New York Heart Association precordial leads are taken on the chest af desired points over a bre extending from the right sternal margin at the level of the fourth intercostal space to the junction of the left midclavicular line with the fifth intercostal space continuing at thus level around the left chest Right-chest lead are taken over the right chest in a similar manner (Fig 11A and B) B Fig 11 Positions of unipolar precordial leads shown by pennies on chest of 6 year old asthmark girl A Posterior anterior view B Left anterior oblique *16W 1 Alter Hecht) 27 ·CHAPTER IV Unipolar Precordial Leads Precorrlın! Unipolar leads According to the criteria of the New York Heart Association precordial leads are taken on the chest at desired points over a bpe extending from the right sternal margin at the level of the fourth intercostal space to the junction of the left midclavicular line with the fifth intercostal space continuing ar thus level around the left chest Right-chest lead are taken over the right chust in a similar manner (Fig 11A and B) A Fig !1 Positions of unipolar precordial kads shown by pennies on chest of year old asthmal girl A Posterior antenor view B Left anterior oblique *16W 1 Alter Hecht) 27 ·UNIPOLAR PRECORDIAL LEADS 29 Ilustration showing average pre intrinsico d deflect ons with normal ranges in V1 and in Vð at d fferent cge groups of normal ch id en Sec. 005 004 [] Av 003 002 aoi CE VI V6 ADO VI V6 VTV6 VI V6 VI V6V V6 1 to 7 2 to 12 1 to 2 2 to 6 6 to 13 Weeks months years years years Adult Table 4 diphasic in the infant becoming less commonly so in the older child where they are usually clearly visible and with greater amplitude than V in other chest leads In the newborn and the infant under 8 weeks an isolated R wave or Rs curve followed by an inverted T wave is the rule for the QRS form in V, The amplitude of the R deflection in Vi gradually decreases with the age of the child so that in the 6- to 13 year old age group an tS is the usual form although the T waves continue to be inverted Very rarely the R waves are absent and a deep QS is present the intrinsicold deflection occurs early in the course of the QRS group (Table 4) In the normal child T in Y, is tarcly upright and the ST junction is frequently elevated The various form of the QRS complex found in V, are attributable in most part to the different positions in which the heart may be found of the electrode should lie over the right ventncle the initial deflection will be an R wave If it lies over the night atnum and faces the great onfices of the heart as it does when the heart is displaced backward and to the left, a QS or iS will be present in this case R is prominent in aVe also and the transition zone will be shifted to the lelt ·29 UNIPOLAR PRECORDLAL LEADS Illustration showing average pre intrinsico d deflect ons with normal ronges in V1 and in Vð at d fferent age groups of normal ch Id en Sec. 005 0.04 -[+] AY 003 HAM 0.02 -- 001 VUE VI V6 000) VI V6 V V6 Vi V6V 76 VIVO 1 to 7 2 to 12 1 to 2 2 to 6 6 to 13 Weeks months years years years Adult Table 4 diphasic in the infant becoming less commonly so in the older child where they are usually clearly visible and with greater amplitude than V in other chest leads In the newbom and the infant under 8 weeks an isolated R wave or Rs curve followed by an inverted T save is the rule for the QRS form in V. The amplitude of the R deflection in V, gradually decreases with the age of the child so that in the 6- to 13 year old age group an tS is the usual form although the T waves continue to be inverted Very rarely the R waves are absent and a deep QS is present The intrinsicold deflection occurs early in the course of the QRS group (Table 4) In the normal child T in V. is rarely upright and the ST junction is frequently elevated The various form of the QRS complex found in V, are attributable in most part to the different positions in which the heart may be found If the electrode should lie over the right ventricle the initial deflection will be an R wave If it lies over the night atrium and faces the great onfices of the heart as it does when the heart 18 displaced backward and to the left, a QS or rS sill be present is this case R is prominent in ave also and the transition zone will be shifted to the left.

·UNIPOLAR PRECORDIAI LEADS 31 1. (The tracing is taken with the exploring electrode placed at the left costosternal margin at the level of the fourth intercostal space ) P waves are occasionally inverted or diphasic in this lead in the child The usual QRS form is an RS curve Rarely a small q wave is seen in infants under 1 year of age Incidence of inverted and d phase S waves are usually deepest in Twoves in precord at leads in 135 this lead although in the younger 100 healthy ch Idren at d fferent agex age groups especially S may be deeper in leads V, and V, than 90 in V Tuaves are commonly in 80 verted in V in the younger child They are inverted in 643 70 per cent of normal children under 6 60 years and 272 per cent in those of 6 to 13 years (Table 4) The 50 S-T junction is usually isoelectric although it may be highly elevated or depressed in this lead (Fig 30 12) 20 1, (The exploring electrode is placed midway between the posi tions for V and V, ) Because of the small size of the child s chest V V2 V 4 this lead and that of V are fre -Peront laveried Twave under 2 y ars quently omitted from the child s 2 to 6 6 to 3 electrocardiogram except in spe ced phos c T wore unde 2 yeos cial instances The initial deflec 2 to 6 6 19 13 tion in V, is usually an R Wate Table 5 and 1 Haves are usually inverted in children under 6 years of age 40 10 0 V6 As the age of the child increases, V shows a ere 1 Iude of the Rw Pnaics are u alcare urr and hig the second ye P and I defiections are upright Small y aves are common after the second year An R curve is usual & all ages in this lead ·UNIPOLAR PRECORDIAI LEADS 31 1. (The tracing is taken with the exploring electrode placed at the left costosternal margin at the level of the fourth intercostal space ) P waves are occasionally inverted or diphasic in this lead in the child The usual QRS form is an RS cure Rarely a small q wave is seen in infants under 1 year of age Incidence of inverted and d phase S waves are usually deepest in Twaves in precord at leads in 135 this lead although in the younger 100 healthy ch Idren at d fferent ages age groups especially S may be deeper in leads V, and VA than 90 in V Txaves are commonly in 80 verted in V in the younger child They are inverted in 643 70 per cent of normal children under 6 60 years and 272 per cent in those of 6 to 13 years (Table 4) The so S-T junction is usually isoelectric although it may be highly elevated or depressed in this lead (Fig 30 12) 1, (The exploring electrode is placed midway between the posi 10 tions for V and V, ) Because of the small size of the child s chest VI V2 V4 V6 this fead and that of V are fre Per ont inverled Twave under 2 y ars quuntly omitted from the child s 6 to 3 electrocardiogram except in spe Pe ce ! d phos c T wore Inde 2 yeos cial instances The initial deflec 6 10 15 tion in V, is usually an R wale Table 5 and 1 waves are usually inverted in children under 6 years of age 40 20 0 2 to 6 2 to 6 As the age of the child increases, V shows a er ein lude of the Rw Phalcs are Ware ate urr wao and he the second ye P and I deflections are upright Small y ayes are common after the second year An R curve is usual e all ages in this lead ·CIAPTER 1 The Childs Electrocardiogram in Disease Bundle Branch Bloch Bundle branch block is due to an obstructing defect or anomaly in the conduction pathway of one or the other of the branches of the bundle of His resulung in delay in activation of the affected ventricle Absent Q waves and broad notched or bifid R waves with delayed intrinsicoid de ficcuons and widened QRS complexes of 0 10 second or morc characterize the tracings over the epicardial surface of the blocked ventricle of the child Narrow R deflections and broad S waves with widened QRS intervals are present over the opposite ventricle (Table 6 and Figs 13a and b 30 35 and 41A) Bundle branch block is not rare in congenital heart disease es pecially in lesions of the atrial septum and less commonly of the ventricular septum It may be found in long standing cases of aortic tegurgitation and mitral stenosis As a transitory finding bundle branch block may be seen in patients with acute infections such as diphthentic myocarditis and acute rheumatic carditis in the early stages of the chronic form transient bundle branch block may be noted it may be seen as a manifestation of toricity during drug therapy such as with quinıdınıza tion Arl ortsatton bloch is the term occasionally used in describing bundle branch block which shows low voltage in the standard limb leads (Fig 14) (Text contained on p 36) 33 ·CIAPTFRI The Child s Electrocardiogram in Disease Bundle Brancl Block Bundle branch block is due to an obstructing defect or anomaly in the conduction pathway of one or the other of the branches of the bundle of His resulting in delay in activation of the affected ventricle Absent Q waves and broad notched or bifid R waves with delayed intnnsicold deflections and widened QRS complexes of 0 10 second or more characterize the tracings over the epicardial surface of the blocked ventricle of the child Narrow R deflections and broad S waves with widened QRS intervals are present over the opposite ventricle (Table 6 and Figs 13a and b 30 35 and 41A) Bundle branch block is not rare in congenital heart disease es pecially in lesions of the atrial septum and less commonly of the ventricular septum It may be found in long standing cases of aortic regurgitation and mitral stenosis As a transitory finding bundle branch block may be seen in patients with acute infections such as diphthenitc myocarditis and acute rheumatic carditis in the early stages of the chronic form transient bundle branch block may be noted It may be seen as a manifestation of toricity during drug therapy such as with quindınıza tion Arl orisation block is the term occasionally used in describing bundle branch block which shows low voltage in the standard limb leads (Fig 14) (Text continued on P36) 33 ·de 100 M ta PARA be Fig 14 Arborization block (bundle branch block with low volt agc) shown in standard limb leads of 10-year-old girl with clinical signs of ventricular septal defect Righe BBB Left BBB NOTCHING OF ORS COMPLEXES WITH QRS INTERVAL 0 10 SECOND OR MORE NOTCHING OF QRS COMPLEXES WITH QXS INTERVAL 0 10 SECOND OR MORT For of QRS curve in limb leads de peous on heart position It is usual to sce late wide S in leads 1 and VL, late ntched Rin VR #xh Rt leads 3 and VF The QRS outline in limb leads depends on the heart position but usually shows bigh R waves in leads 1 and VL with deep Sor QS in leads 3 F and VR QRS complexes in V and y usually Show TR curves with wide and tall R und in crted T Waves QRS 18 V and V usually shows QS or rs with elevated RT segment and upright T QRS in V V and V usually show's QRS with prominent S and upright T QRS in V and usually shows absent waics notched R waves with depres ed RT segment and inverted T The intrinsicold deflection is delayed Over the right precordium starting 002 second or more after the onset of the QR curve and is normal over the left venincic The intrinsicold deflection is late over ih left precordiun starting 004 stcard or more after the QRS onset and is normal over the right ventricle Table 6 Differentiation between night and left bundle branch block in th child ·at mitt We .. KAI V eee tu CA LA vere wed Fig 14 Arborization block (bundle branch block with low volt age) shown in standard limb leads of 10-year-old girl with clinical signs of ventricular septal defect Right BBB Left BBB NOTCHING OF ORS COMPLEXES WITH QRS INTERVAL 010 SECOND OR MORE NOTCHING OF QRS COMPLEXES WITH QAS INTERVAL 0 10 SECOND OR MORT Form of QRS curve in limb leads de pends on heart position It is usual to sce late wide S in leads 1 and VL late ntbed R In VR with Releads 3 and VF The QRS outrne in limb leads depends on the heart position but usually shows bigh R waves in leads 1 and VL with deep Sor QS in leads 3 F and VR QRS compleres in V and Y U$ally QRS 1 V and V usually shows QS Show TR curves with wide and tall R or rs with elevated RT segment and und in crted T Waves upright T QRS in V V and V usually show's GRS *ith prominent S and uprigh: T QRS in V and V usually shows absent Q walcs notched R waves with depres ed RT segment and inverted T The intrinsicold deflection is delayed Over the right precordium starting 002 second or more after the onset of the QR curve and is normal over the left 1entracte The intrinsicold deflection is late over 1h left precordium starting 004 second or more after the QRS onset and is normal oser the right ventricle Table 6 Differentiation between night and left bundle branch block in th child 35 ·37 THE CHILDS ELECTROCARDIOGRAV I DISEASE sigus or vagal stimulation The PJ segment will then be seen to be equal to the PJ segment found during a cycle of ectopsc rhythm This is not the case in true bundle branch block, where the blocked P I segmeat is increased in duration Cardiac llypertrophy Cardiac hypertrophy is usually first localized to a single heart chamber There is an increase in the size and weight of each muscle fiber in the muscle mass affected Other chambers may or may not be involved later in the course of the disease Atrial fiypertropliy may be found in patients in whom an in creased load is present in the atna of the heart as in those with pulmonic tricuspid or mitral stenosis ainal septal defects pulmonarv disease and certain types of myocardial infarction In such cases where there is marked atrial activity the P waves may be wider than 011 second and as high as 25 mm They may be peaked tall broad notched or slurred and are best seen in V, V VR and VL leads (Fig 56A and C) Hypertrophy of either rentrele commonly shows a delay in the duration of the intrinsicold deflect on in the tracing talen over the hypertrophied ventricie in comparison with that taken over the normal ventricle The R waves are usually markedly increased in voltage and small s deflections with depressed ST segments may be seen » Iads facing the hyperrophied ventrcle while the inverse is found over the normal venircle The QRS interval 15 moderately increased to 0 1 or 011 second over an hypertrophied left ventrcle ard the transitional zone will be noted to be nearer the affected ventrcle than normal Left rentricular krpertrophy, as may commonly be found in such conditions as tricuspid ztrests and aortic stenoses marked co arctation of the aorta and long standing setere patency of the ductus arteriosus may show the following changes 1, and Icads facing the right sentncle show iS or QS waves with no delay in the intrinsicoid deflection The S-T segment is elevated in these tracings and T 15 vpnght 1, and leads facing the hypertrophied left ventricle commonly ·37 THE CHILDS FLECTROCARDIOGRAWN DISEASE sious or vagal stimulation The PJ segment will then be seen to be equal to the PJ segment found dunng a cycle of ectopic rhythm This is not the case in true bundle branch block, where the blocked P I segmeat is increased in duration Carilac llypertrophy Cardiac hypertrophy is usually first localized to a single heart chamber There is an increase in the size and weight of each muscle fiber in the muscle mass affected Othes chambers may or may not be involved later in the course of the disease Atrial hypertrophy may be found in patients in whom an in creased load is present in the atna of the heart as in those with pulmonic tricuspid or mitral stenosis atna) septal defects pulmonarv disease and certain types of myocardial infarction In such cases where there is marked atrial activity the P waves may be wider than 011 second and as high as 25 mm They may be peaked tall broad notched or slurred and are best seen in V, V VR and VL leads (Fig 56A and C) Hypertrophy of either ventricle commonly shows a delay in the duration of the intrinsicoid deflect on in the tracing talen over the hypertrophied ventricle in comparison with that taken over the normal ventrale The R waves are usually markedly increased in voltage and small S detections with depressed S T segments may be seen » kads facing the hypertrophied ventricle while the inverse is found over the normal venircle The QRS interval is moderately increased to 01 or 0 14 second over an hypertrophied left ventncle ard the transitional zone w!! be noted to be nearer the affected ventricle than normal Left tentricular krpertrophy, as may commonly be found in such conditions as tricuspid atrests and aortic stenoses marked ca arctation of the aorta and long standing setere patency of the ductus arteriosus may show the following changes !, and leads facing the night sentncle show iS or QS waves with no delay in the intrinsicard deflection The S-T segment is elevated in these tracings and T s vpright te and leads facing the hypertrophied left ventricle commonly ·THE CHILDS ELECTROCARDIOGRAM IN DISEASE 39 intervals and nght axis deviation However with the heart in a horizontal electrocardiographic position left aus deviation may be found and occasionally in this position an IS curve may be seen in all standard limb leads QR complexes are the rule in VR leads and Q waves with T inversion are common in leads 2 3 and VF (Figs 36A and 48) Differentiation of right ventricular hypertrophy from night bundle branch block is difficult at times the shorter QRS interval and absence of notching of the R waves over the hypertrophied ventncle together with the presence of small R waves over the left pre cordium suggest hypertrophy rather than ngbt bundle branch block (Figs 13a 36A and 46) Ventricular Strai Ventricular strain* has been described as a functional disturbance of heart muscle which is usually reversible and whose electrocardiographic signs are similar to those of muscle injury which affects the repolarization process only S-T segments become depressed and T waves inverted while the QRS curves remain unchanged It has been suggested that when the ST T changes as noted above are found without increase in amphtude of R and S waves ventricular strain without hypertrophy may be presupposed and that when the S-T T changes described above are not found in the presence of increased amplitude of R and S deflections hypertrophy without ventricular strain is present also that combined QRS S-T and T changes suggest the presence of hypertrophy with strain Ventricular Ysocardial Infarction Ventat ular myocardial infarction follows an acute ischemia of a part of ventricular muscle #kose blood oxygen supply is either sud denly cut off or becomes 15adequate for its nutnuonal derbands The affected muscle becomes necrotic and is rephced by fibrous tissue The lesion is rare in the child and the diagnosis may be easily missed Coronary circulation in the child differs from that of the adult. In the There h s becs cnties of the use of the term "eptnculat strain" in electrocardiograpluc merpretation ·39 THE CHILDS ELECTROCARDIOGRAM IN DISEASE intervals and nght axis deviation However with the heart in a horizontal electrocardiographic position left aus deviation may be found and occasionally in this position an IS curve may be seen in all standard limb leads QR complexes are the rule in VR leads and Qwaves with T inversion are common in leads 2 3 and VF (Fig$ 36A and 48) Differentianon of right ventricular hypertrophy from night bundle branch block is difficult at times The shorter QRS interval and absence of notching of the R waves over the hypertrophied ventncle together with the presence of small R waves over the left pre cordium suggest hypertrophy rather than nght bundle branch block (Figs 13a 36A and 46) Ventricular Straits Ventricular strain* has been described as a functional disturbance of heart muscle which is usually reversible and whose electrocardiographic signs are similar to those of muscle injury which affects the repolarization process only S-T segments become depressed and T waves inverted while the QRS curves remain unchanged It has been suggested that when the ST T changes as noted above are found without increase in amplitude of R and S waves ventricular stran without hypertrophy may be presupposed and that when the S-T T changes described above are not found in the presence of increased amplitude of R and S deflections hypertrophy without ventricular strain is present also that combined QRS S-T and T changes suggest the presence of hypertrophy with strain Ventricular Vsocardial Infarction Ventricular myocardial infarction follows an acute ischemia of a part of ventricular muscle whose blood oxygen supply is either sud denly cut off or becomes 15adequate for its nutnuonal demands The affected muscle becomes necrotic and ss rephced by fibrous tissue The lesion is rare in the child and the diagnosis may be easily missed Coronary circulation in the child differs from that of the adult. In the There has been cntics of the use of the term "Yentricular straja" in electro cardiograpluc merpretation, ·THE CHILDS ELECTROCARDIOGRAM IN DISEASE 39 intervals and reht axis deviation However with the heart in a horizontal electrocardiographis position left axis deviation may be found and occasionally in this position an rS curve may be seen in all standard limb lead, QR complexes are the rule in VR leads and Quales with T inversion are common in leads 2 3 and VF (Figs 36A and 48) Diferennanon of nghi ventricular hypertrophy from night bundle branch block is difficult at times The shorter QRS interval and absence of notching of the R Hayes over the hypertrophed sentricle together with the presence of small R waves over the left pre cordium suggest hypertrophy rather than right bundle branch block (Figs 13a 36A and 46) Ventricular Sırain Versicular strain* has been described as a functional disturbance of heart muscle which is usually reversible and whose electrocardiographic signs are similar to those of muscle injury which affects the repolarization process only S-T segments become depressed and Twaves invered while the QRS curves remain unchanged It has dcen suggested that when the S-T T chinges as poted above are found without increase in amplitude of R and S Haves ventricular strain without kspertrophy may be presupposed and that when the ST T changes described above are not found in the presence of increased amphold of R and S deflecuons hypertrophy without ventricular strain is present also that combined QRS ST and T changes suggest the presence of hypertrophy with strain Ventricular Vyocardial Infarction Ventricular myaardial infarcuon follows an acute ischemja of a part of senincular muscle #hose blood oxygen supply is either sud denly cut off or becomes inadequate for its nutritional demands The affected muscle becomes necrotic and is replaced by fibrous tissue Theksion is rare in the child and the diagnosis may be easily missed Coronary circulation in the child differs from that of the adult. In the There has been anticism of the use of the term reglugular slysis" 19 Han CITA Detinh nimalatın ·THE CHILDS ELECTROCARDIOGRAM IN DISEASE 39 intervals and n_ht axis deviation However with the heart wa horizontal electrocardiographis position left axis deviation may be found and occasionally in this position an IS curve may be seen in all standard limb leads QR complexes are the rule in VR leads and Q wales with T inversion are common in leads 2 3 and VF (Figs 36A and 48) Diferennanon of nghi ventricular hypertrophy from nght bundle branch block is difficult at times The shorter QRS interval and absence of notching of the R wayes over the hypertrophied ventricle together with the presence of small R waves over the left pre cordium suggest hypertrophy rather than right bundle branch block (Figs 13a 36A and 46) Ventricular Sirain Verxscular sirainº has been described as a functional disturbance of heart muscle which is usually reversible and whose electrocardiographic signs are similar to those of muscle injury which affects the repolarization process only S-T segments become depressed and T waves inverted while the QRS curves remain unchanged It has been suggested that when the S-T T changes as poted above are found without increase in ampliçude of R and S Haves ventricular strain *Anout kypertrophy may be presupposed and that when the ST T changes described above are not found in the presence of increased ampıld of R and S deiections hypertrophy without ventricular strain is present also that combined QRS ST and T changes surgest the presence of hypertrophy with stram Ventricular Vyocardial Infarction Ventricular myaandial infarction follows an acute ischemia of a part of senincular muscle whose blood oxygen supply is either sud denly cut off or becomes taadequate for its nutritional demands The affected muscle becomes necrotic and is replaced by fibrous tissue Theksion is rare 10 the child and the diagnosis may be casily mnissed Coronary circulation in the child differs from that of the adult. In the There has been chticism of the use of the term pentru ulaz slais" in teava cand defaphic hiepretation ·41 THE CHILDS ELECTROCARDIOGRAY IN DISEASE The lesion 15 transmural and is most frequently found in the anterior and apical portions of the left ventrcle which is the area supplied by the antenor descending branch of the left coronary artery the vessel most usually affected Occlusion of the night coronary artery will cause infarction of the posterior wall of the left ventricle and often mcludes the postenor portion of the septum in the affected area The electrocardiographic diagnosis is made only on characteristic changes in the QRS complexes with ST displacements and, or typical Twave changes The first electrocardiographic sign of myocardial infarction which may be found is typical of muscle injury and is represented by an upuard displacement of the RS T segment over the affected area The elevation is usually transitory and of short duration and a dis appears when the affected muscle dies or recovers The volta e of the positive intrinsic deflection decreases and may disappear whide a decp ne ative or Q wave appears over the necrosed area this being incapable of impulse response allows the porenual 253911ons of the adjacent ventricular cavity to be transmitted through the un'arcten to the overlying electrode If portions of living muscle are present in the lesson small R waves or notching of the waves will be seen These sigies may be transient or permanent T waves registered from marginal epicardial portions of the necrosed area may become deeply sserted in their terminal portions and may remain so indefinitely When electrocardiographic signs of myocardial infarction are present progressate changes are early and rapid 13 serial tracings An anteroseptal wall infarction of the left ventricle may show typical changes in LJ VL V V V, and V, In anterolateral wall infarction disturbances may be seen as well in leads V and Vo w Lumplex is present in an depressed and inverted I waves The S-T segment is depressed in and elevated in V. Interpolated and ectopic suscular beats se present in leads I and in ay ·THE CHILDS ELECTROCARDIOGRAY IN DISEASE The lesion 15 transmural and is most frequently found in the anterior and apical portions of the left ventricle which is the area supplied by the antenor descending branch of the left coronary artery the vessel most usually affected Occlusion of the nght coronary artery will cause inlarction of the posterior wall of the left ventricle and often includes the posterior portion of the septum in the affected area The electrocardiographic diagnosis is made only on characteristic changes in the QRS complexes with S T displacements and, or typical Twave changes The first electrocardiographic sign of myocardial infarction which may be found is typical of muscle injury and is represented by an upward displacement of the RS T segment over the affected area The elevation is usually transitory and of short duration and a dis appears when the affected muscle dies or recovers The volta e of the positive intrinsic deflection decreases and may disappear whde a deep ne ative or Q wave appears over the necrosed area this being incapable of impulse response allows the porental 25111ons of the adjacent ventricular cavity 10 be transmited through the un'arction to the oveslyang clectrode If portions of hying muscle are present in the lesion small R saves or notching of the Q waves will be seen These signs may be transient or permanent T waves registered from marginal epicardial portions of the necrosed area may become deeply inserted in their terminal portions and may remain so indefinitely When electrocardiographic signs of myocardial infarction are present progressive changes are early and rapid 13 serial tracings An anteroseptal wall infarction of the left ventricle may show typical changes in LJ VL V V V and V, In anterolateral wall infarction disturbances may be seen as well in leads V and Vo Lumplex is present in allu depressed and inverted I waves The ST segment is depressed in and elevated in V. Interpolated and ectopic auricular beats se present in leads I and in ay ·4 THE CHILD S ELECTROCARDIOGRAM IN DISEASE nomonic of the condition those showing deep S waves and pe sistent displacement of RST segments in leads 2 and 3 togeth with high R and upright T *ves in VR and tho e having deep or OS deflections with inverted T waves in lead 1 and high R wav in lead 3 Unusual rotations of the heart following myocardial inju arc the main causes of these electrocardiographic changes Kheumatic Fever Transitory electrocardiographic changes are usually present some degree in acute rheumatic carditis During my intereshup and later while attending on the Childre Service at Bellevue Hospital in the 1920 s I studied a group of 1 children of 13 years and under who bad active rheumatic card and to whom digitalis was given only rarely and sparingly at t ome Electrocardiograms were also then repeated only occasiona but each child in the group had at least one iracing talen the 61 shosed first-degree a v block 11 second-degree block while 4 children complete a v dissociation was present Atrial fibrilla occurred in 9 cases of whom the youngest was 9 years old (7 of 11 hildren died within a few month after the onset of fibrillata I could showing atrial fibrillation combined with complete a v bl And I ventricular fibrulation as a terminal event The findings depend upon the seventy and location of the les It these are diffuse abnormalities may be found in all parts of cardiac cycle with P waje and QRS cure widening and note! S-T displacements and T wave changes Disturbances of im conduction in the uncharted pathways of the atna or in the bu of His and its branches are recognized by a widening of the P when the lesson 137 the art or by a prolongation of the PR QRS intervals when in the ap gode the bundle or its bran When there is delay in the pasion and retrest of the im thround inlammatory Teacion of the veninculas mu dle the segment shows an increase in time duration If the epicardial se of th heart is alecsed as in acute pericarditis S-T displacement DT ·THE CHILD S ELECTROCARDIOGRAY IN DISEASE 43 nomonic of the condition those showing deep S waves and per sistent displacement of RST segments in leads 2 and 3 together with high R and upright T waves in VR and tho e having deep or OS deflections with inverted T waves in lead 1 and high R waves in lead 3 Unusual rotations of the heart following myocardial injury are the mass causes of these electrocardiographic changes Kleumatic Fever 10 Transitory electrocardiographic changes are usually present some degree in acute rheumatic carditis During my intemeshup and later while attending on the Childrens Service at Bellevue Hospital in the 1920 s 1 studied a group of 108 children of 13 years and under who bad active rheumatic carditis and to whom digitalis was given only rarely and sparingly at that ume Electrocardiograms were also then repeated only occasionally but each child in the group had at least one racing taken of these 68 showed first-degree a v block 11 second-degree block while in 4 children camplete a v dissociation was present Atrial fibrillation occurred in 9 cases of whom the youngest was 9 years old (7 of these hildren died within a few month after the onset of fibrillation) I child showing atrial fibrillation combined with complete a v block and I ventricular fibrulation as a terminal event The findings depend upon the seventy and location of the lesion If these are diff se abnormalities may be found in all parts of the cardiac cycle with P wale and QRS curse widening and nothing S-T displacements and I wave changes Disturbances of impulse conduction in the uncharted pathways of the atna or in the bundle of His and its branches are recognized by a widening of the P wate then the lesion 18 3n the aim or by a prolongation of the P R and QRS intervals when in the P code the bundle or its branches When there is delsy in the usasion and retreat of the impulse throul inllammatory reacion of the venincular mu cle the QT segment shows an increase in time duration If the epicardial surface of th heart is allecsed as in acute pericarditis S-T displacements and DT ·45 THE CHILDS ELECTROCARDIOGRAM IN DISEASE Fig 17A Standard limb leads taken over Consecutive w.cc*S OD 12 year C The T deflections have become deeply inverted in all leads and she ST scements are sovlecenc hws cove to show upward convexity and the QT of 0 407 second is again above tormal # The Cracing teluras to Origtaal farm. The QT continues to be prolonged at 0 403 second Icute Rheumatic Periegrdm Acute pericarditis frequently shows a typazi electrocardiogram in the early stages of the atvie par ss The changes are usually rapid and transitory depending bonect on the nature of the infection They are charactensiir of spycardiał mjury and adiect first the deviation of the ST segment and later the T deflection The first sign is a notice able elevation of the S-T segmen in the three standard Jimb leads (Text corgifted on 48} ·45 THE CHILDS ELECTROCARDIOGRAM IN DISEASE Fig 17A Standard und leads taken over Consecutive wee%S OB 3 12 year The T deflections have before deeply inverted in all leads and she ST segments are sorlecinc bus c' ove to show upward convexity and the QT of 0 407 second is again above normal The racing teluras ta original farm. The QT continues to be prolonged #10403 second Icute Rieumalje Peregrdm Acute pericardites frequently shows a typauzi electrocardiogram in the early stages of the atvie pass The changes are usually rapid and fronsitory dependine bonect on the nature of the infection They are charactensiir di pacardial mjury and siect first the deviation of the 57 segment and later the T deflection the first sign 15 a notice ubic elevation of the S-T segmen in the three standard limb leade (Text continued on 48) ·47 Fig 17C Two cases of ch ldren with active cheumatic lever in cariy stage 2 Lima and precordial lends of an 8 jear-oll boy showing rap sinus rhythm and sluggish a v conduction The P R ir ervalys I second b Standar i limb leads of an & utely I boy of 13 years with infamed and tender joints The PR inferral is O 21 second and the RT segments im Jeads 2 and 7 are cle: ate! The P Waves Ase Hide and the PR segment is depressed in leads 1 and 2

·$
$
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th
مال
U11
22
47
Fig 17C Two cases of ch ldren with active theumatic ever in carly stage
Lima and preconiai lerds of an 8 year-olt boy shouing raped Sinus rhythm and siuggish
a v conduction The P R ir ervais ? sesong
b Standari limb leads of an & utely fl boy of 13 years with infiamai and sender joints The
PR meryal is 21 second and the RT segments to leads 2 and 3 are cles ate! The P Waves
ase wide and the PR segment is depressed in leads 1 m 2

·49 THE CHILDS ELECTROCARDIOGRAM IN DISEASE ' Fig 19 Standard and unipolar limb leads and unipolar precordial leads from a 16 year old boy with actre rheumatic aortic disease and hypertension The tracing shows sinus rhythm with marked left axis deviation and early left ventricular hypertrophy The d ep S present in lead 3 does not change on deep in piration in cases of left ventricular hypertrophy hydrostanc pressure in the pericardial sac The QT interval » linually normal Constrietre pertenrditis may be recognized in the electrocardiogram by the finding in serial tracings of a rapid and steady decrease of wale amplitudt in all leads toveiher with an increase in the heart rate T waves are frequently inverted in the late stages of constrictive pericarditis the voltage is extremely low Similar low voltage is seen in advanced untreated hypothyroidism where the heart rate is how cser very slos in contrast so that of constrictive pericarditis (Figs Sb and 23) ·49 THE CHILDS ELECTROCARDIOGRAM IN DISEASE TE WRIT Fig 19 Standard and unipolar limb leads and unipolar precordial leads from a 16 year-old boy with nacine rheumatic aortic disease and hypertension The tracing shows sinus rhythm with marked left axis deviation and early left ventricular hypertrophy The dep S present in lead 3 does not change on deep in piration in cases of left ventricular hypertrophy hydrostatic pressure in the pericardial sac The QT interval » llwally normal Constriedire pericarditis may be recognized in the electrocardiogram by the finding in serial tracings of a rapid and steady decrease of wale amplitude in all leads toreiher uith an increase in the heart rate T waves are frequently inverted in the late stages of constrictive pericarditis the voltage is extremely low Similar low voltage is seen in advanced untreated hypothyroidism where the heart rate is how cver slow in conirase lo that of constrictive pericarditis (Figs Sb and 23)

·31
THE CHILD'S ELECTROCARDIOGRAL IN DISEASE
NA
w
A.
pe
OSCARON
LAV
AM
Mee
FOR
SONO
Fig 21 a Atrial fibrillation in case of 10-year-old boy with rheumatic
carditis and mitral stenosis Coarse "f" Haves of fibrillation and right aris
deviation are present. Digitalis effect noted by depressed and inverted T waves
in leads and 3
Standard mb leads taken from 14-year-old boy with aortic insufficiency
of theumatic origin. Conduction is delayed in the entire pathway the PR
Interval being 074 second and the QRS 011 second Marked left axis devia
tion 15 present
effect may result from an abrupt reversal of shunt in a wide septal
defect. The clectrocardiogram often shows characteristic signs of
Tight seninculat strain and hypertrophy of sudden appearance
and if the patient should survive as sudden disappearance There are
deep S waves and depressed S T segments to lead 1 with deep Q
and clevated S-T segments in lead 3 T wales are inverted in lead 3
and over the night precordium where also R waves are often noted
The condition is most rare in a child

·$1
THE CHILD'S ELECTROCARDIOGRAV IN DISEASE
COM
pen
C G
LE
00
4
20
AN
VA
OM
EN
Fsg 21 Atrial fibrillation in case of 10-year-old boy with rheumalis
carditis and mitral stengsis Coarse "f" Waves of fibrillation and right axis
destation are present. Digitalis effect ndled by depressed and inverted T waves
in leads and 3
6 Standard mb leads taken from 14-year-old boy with aortic insufficiency
of rheumatic origin. Conduction is delayed in the entire pathway the PR
interval being 0 ?4 second and the QRS 011 second Marked left axis devia
tion is present
effect may result from an abrupt reversal of shunt s a wide septal
defect. The electrocardiogram often shows characteristic signs of
right ventricular strain and hypertrophy of sudden appearance
and if the patient should suryue as sudden disappearance There are
deep S waves and depressed S T segments in lead I with deep Q
and clevated ST segments in lead 3 T yases are inverted in lead 3
and over the night precordium here Also R waves are often noted
The condition is most rare in child

·THE CHILDS ELECTROCARDIOGRAM IN DISEASE 53 Fig 3 Standard limb Icad tracing with resersed rype leat CFL-sp occasionally is old drops of books on electrocardiography from 12 year old girl with constructive Pesxardros There is marked low voltage The heart rate is tapid (113 per minute The PX 7 erval s 16 second The QT interval of 407 second s prolonged T Wav s are merred mn ſcad 3 and slightly diphasxc leads 1 and 2 An Occasiaal ventricular premature contraction is present Digitalis and the Flectrocardiogram The desired and usual therapeutic effect of digitals is in slowing the hcartbeat Besides 278 derectly on heart muscle digitalis acts on the cardioshsbstory center and through vagal stimulation de presses the conduction of impulses between the atna and ventricles The heart rate is lowered the PR interval is lengthened and the QT interval is shortened as the lasered level of sensitivity to caícium present in the heart in farlore again becomes normal The normal upsurd concasity of the S-T segment is deepened and the segment becomes depressed except occasionally in the VR 1~3d where it may bu elevated These efforts may be seen in precordia) as well as in standard limb leads \aintained digitalis effect is followed by a louching of T #21e ampitude and final inversion of the T delection (Fies 2s 35 and 36B) ·THE CHILDS ELECTROCARDIOGRAN IN DISEASE Fig 3 Standard limb icad trating Texersed type leal CF 650D occasionally is old tdstions of books on electroxardiography from 12 year old girl with constrictive pericarditas Tk reis marked low voltage The heart rate is rapid (113 per minute! The PR erval is 016 second The QT interval of 0407 second is prolonged T way s are mierted in ſcad 3 and slightly diphasic up leads 1 and 2 Ad occasional ventricular premature contraction is present Digitalis and the Flectrocardiogram The desired and usual therapeutic effect of digitals is in slowing the heartbeat Besides ar 78 directly on heart muscle digitalis acts on the cardioinhibitory center and through vagal stimulation de presses the conduction of impulses between the stra and ventricles The heart rate is lowered the PR intertal is lengthened and the QT interval is shortened as the lowered level of sensitivity to calcium present in the heart ta fallure again becomes normal The normal upward concavity of the S-T segment is deepened and the segment becomes depressed except occasionally in the VR 143d where it may bu elevated These elas may be seen in precordial as well as in standard limb leads tintained digitalis effect is folloned by a loucring of T le amphitude and final inversion of the T deflection (Figs a 35 and 36B) ·Tabwe T #t a ើ Fig 25 a b Digitalis effect seen in standard lemb leads of two children receiving digitalis for hcart faulure Tracing show's slow atrial fibrillation with slight right axis deviation and coarse atrial oscilla tions S-T segments are deeply de pressed in leads 2 and 3 From a 10-year-old boy with mural lessons and failure b Rapid atrial fibrillation with right at deviation coarse atrial oscillations and frequent ventricu lar premature contractions The ST segments in leads 2 and 3 are -T depressed and concave downward Tracing of a 9 year old boy with metral disease с Tracing showing digitalis ef fect in an adolescent boy (AF) with diagnosis of rheumatic ortic Insufficiency Sinus thythm is present with fre quent interruption by ventri ular premature contractions There is left avis destation with semihorizontal clectrocardiographic position of the hean The ST segments in leads 1 2, a Vy a V V V and V are depressed and concave upward ? fetusit 55 ·Cautari mya_ ។ Fig 25 a b Digitalis effect seen in standard limb leads of two children receiving digitalis for heart failure a Tracing show's slow atrial fibrillation with slight right aris deviation and coarse atrial oscilla tions S-T segments are deeply de pressed in leads 2 and 3 From a 10-year-old boy with mitral lesions and failure b Rapid atrial fibrillation with right axis deviation coarse atrial oscillations and frequent ventricu Iar premature contractions ST segments in leads 2 and 3 are depressed and concave downward Tracing of a 9 year old boy with moral disease Tracing showing digitalis ef fect in an adolescent boy (AF) with diagnosis of rheumatic aortic Insufficiency Sinus rhythm is present with fre quent interruption by ventri ular premature contractions There is teft avis destation with semihorizontal electrocardiographic position of the hean The ST segments in leads 1 2, als aV V V and V are depressed and concave upward ? The с 55 ·CHAFTER Y The Electrocardiogram in Congenital Heart Lesions Congenital Heart Disease and the Electrocardiogram The electrocardiograms of many children with congenital heart lesions show no differentiating signs from those of the normal childs tracing Simular negative findings may be seen in the electrocardiogram of the newborn infant with congenital heart disease in whom characteristic changes may appear as soon as the effect of mechanical stratn becomes evident on ventricular muscle and anatomic position Other trauings of children with congenital heart lesions however fall urd r specific types which may aid in the diagnosis of the lesion or lesions present Some give electrocardiographic evidence of marked positional changes owing to abnormal rotations of the heart caused by the cardiodynamics of the lesions present Some tracings again may be typical of right or left ventricular "strain or hyper frophy It should be noted in this connection that ventriculr hyper trophy is recognized best in the unipolar precordial leads and that vation of the electrical ax to the right or left in the standard himb leads is frequently due to rotation of the heart and reliance on this sign as an indication of hypertrophy is often misleading. Marked right or left axis deviation is howeser usual evidence of hypertrophy of the respectre ventncłe Other tracuags way show diphasic QRS complexes two or more of the standard limb leads in which the 57 ·CHAPTER 12 The Electrocardiogram in Congenital Heart Lesions Congenital Ileart Disease and the Electrocardiogram The electrocardiograms of many children with congenital heart lesions show no differentiating signs from those of the normal childs tracing Simular negative findings may be seen in the electrocardiogram of the newborn infant with congenital heart disease in whom charakteristic changes may appear as soon as the effect of mechanical strain becomes evident on ventricular muscle and anatomic position Other tracings of children with congenital heart lesions however Tall und r specific types which may aid in the diagnosis of the lesion or lesions present Some give electrocardiographic evidence of marked positional changes owing to abnormal rotations of the heart caused by the cardiodynamics of the lesions present Some tracings again may be typical of right or left venincular "strain or hyper trophy It should be noted in this connection that ventricular hyper trophy is recognized best in the unipolar precordial leads and that & viation of the electrical axis to the right leit in the standard himb leads is frequently due to rotation of the heart and reliance on this sign as an indication of hypertrophy is often misleading. Marked right or left axis deviation is however usual evidence of hypertrophy of the respectre ventricłe Other tracings way show diphasic QRS complexes to or more of the standard limb leads in which the 57 ·61 ELECTROCARDIOGRANI IN CONGENITAL HEART LESIONS Tug 29 A Ficcirocar diogram of 2 year-old girl IL de R) with coarctation of the aorta (Acknowledg ment to Dr Eduard Hardy ) The tracing shows sinus rhythm with no deviation of the electrical Atis and inde 1. terminate clectrocardiograph YS position B Electrocardiogram taken in EU a 14 year old girl with coarctation of the aorta and arrested sub- U. bacterial endarteritis and cal cified mycotic aneurysm be low the site of coarctation The findings were corroborated by autopsy The electrocardiogram shows sinus rhythm with low voltage in lead 3 (The clinical findings in this case were described in Am lieu !! 20 3 7 1940) Subaortic stenosis Owing to 1 de elopmental arrest in the in solution of the bulbus cordis a shelflike band of tissue persists below the aortic valves Electrocardiographic findings are similar to those noted above (Fig 30) Bicuspid aortic sale No characteristic electrocardiographic signs ar Cound in this lesias (Fig 31) ·ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS 61 FUTTE Tug 29 A Flectrocar diogram of 2 year old girl (L de R) with coarctation of the aorta (Acknowledg ment to Dr Eduard Hardy ) The tracing shows sinus rhythm with no deviation of the electrical 4tis and inde terminate clectrocardiograph YS posilton B Electrocardiogram taken in Eva 14 year old girl with coarctation of the aorta and arrested sub- . bacterial endarteritis and cal cified mycotic aneurysm be low the site of coarctation The findings were corroborated by autopsy The electrocardiogram shows sidus rhythm with low Soltage in lead 3 (The clinical findings in this case were described in Am lleu 11 20 3 7 1940 ) Subaortic stenosis Owing to a derelopmental arrest in the in volution of the bulbus cordis a shelflike band of tissue persists below the aortic valves Electrocardiographic findings are similar to those noted above (Fig 30) Bicuspid aortic vahe do characteristic electrocardiographic signs ar ſound in this lesion (Fig 31)

·65
ELECSXOCARDIOGRANO IN CONGENITAL HEART LESIONS
F8 33 Tracing showing sytus byihm with righe axis deusaison and heart
in the vertical tlectrocas! Astyn
erer
defec
Ara
1
The X
Pun 10DIC CONUS
All as telected by Dr Ruth udmore >
The electrocardiogram in anomalies of the coronary artertes
Caronary arteries mav vary :7587€ if oumber in disinbution and
monuin The most important clinical anomaly of the coronary
system found in those cases where the coronary artery arises from
the pulmonary artesy Here signs of coronary insufficiency and
my Kardial ischemia sppest Patches of redge shaped degeralation

·ELECSKOCARDIOGRAM IN CONGENITAL HEART LESIONS 65
Spe
.
For 33 Tracing showing 8us sbythm with right axis devszkion and heart
in the veryca tlectrocas stund
16
arter
defec
3
The X
PulloDIC conus
ALL as tctered by Dr Ruth Cudmore >
The electrocardiogram in anomalies of the coronary arteries
Caronary arteries mav vary in site in aumber in distribution and
mongin The most important clinical anomaly of the coronary
system found in those cases where the coronary artery anses from
the mountary artery Here signs of coronary insufficiency and
myocardial chemia appxst Patches di Nedge shaped degen-iglion

·67 ELECTROCARDIOGRAY IN CONGENITAL HEART LESIONS For Rigbt hundie branch block is seen in this case (AF) of 2* as vue LLL partial states inversus the chambers of the heart are reversed A Miror image of icad 1* us present in the electrocardio sam and leads 2 and 3 are interchanged Two of the unipolar limb leads are also interchanged VR taking the character of the normal VL lead and VL resembling a usual VR lead Precordial leads are simill38 en those over the right chest in the normally placed hean (Figs 38 and 39) less commonly an isolated dextrocardia with reversal of heart Chambers 1$ scen Differentiation from the above form is made by physical and fluoroscopic examination as electrocardiographic changes described above are also present in this condnion (Fig. 40) 1 dlat à dextrocardia without reversal of heart chambers may be congenital but is commonly associated with external factors which use a marked countercloch ISE folation of the heart on us long axis The right venincle will then be shifted to the right and dorsed Look Rio mut on a sfant in front of the tracing + cfore the observer teadoptat uprisht Also the right and left arm electrodes are reverend the outlne will be upright ·67 ELECTROCARDIOGRAY IN CONGENITAL HEART LESIONS Fig 35 Rifbt hundre branth block is seen in this case (AF) of at al vuci LILL parttal sietes inversus the chambers of the heart are reversed A motor image of icad I* us present in the electrocardiogram and leads 2 and 3 are interchanged Two of the unipolar limb leads are also Interchanged VR taking the character of the normal VL lead and resembling a usual VR lead precordial leads are similar to those over the right chest in the normally placed hean (Figs 38 and 39) Iess commonly an isolated dextrocardia with reversal of heart chambers is scen Differentiation from the above form is made by physical and fluoroscopic examination as electrocardiographic changes described above are also present in this condnion (Fig 40) I dia a dextrocardia without reversal of heart chambers may be congenital but is commonly associated with external factors which que a marked counterclochusse rotation of the hegn on us long axrs The right venincle will then be shifted to the sight and dorsad Loot into ID me on a sfant in front of the tracing 1cfort ibe observer tead IDPCat upright Alo de right and left arm electrodes Ate revered the outlne will be pright

·69
ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS
1
1
5
Fig 37 Trac ppf minha
With severe "colic
nosis and d ed sh
murmurs were al
in this type of ca
They 1 1
utilaily om was prominent ant tortuous The
Ich actum and ventricle were hypertrophied and dilated and showed extensive
fibrosis Muroscopically endocardial fibrosis was marked Subendocardial ne
crosis and myocardial degeneration and forosis were present.
of Group 3 The positional changes present however disappear on
removal of the oftending agent (Fig 41A and B)
Dexrrocardia combined with pulmonic sienosis shows a mirror
picture of lead ) 19 #hich a large R deflection is present R is also
prominent (Fig 42)
The eletrocardiogram it uncomplicated Fisenmenger's com
plex In this not uncommon congenital heart lesion a dextroposition
of the aorta with a high interventricular septal defect and dilated or

·69
ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS
.
EN
1-
$
Fig 37 Trac ppf minha
With severe "colic
nosis and d ed sh
murmurs were al
in this type of ca
They are 1
ullaily out was prominent ant tortuous The
lett alctum and ventricle were hypertrophied and dilated and showed extensive
fibrosis Microscopically endocardial fibrosis was marked Subendocardial ne
crosis and myocardial degeneration and forosis were present.
of Group 3 The positional changes present however disappear on
removal of the oftending agent (Fig 41A and B)
Dextrocardia combined with pulmonic stenosis shows a mirror
picture of lead ) in which a large R deflection is present R is also
prominent (Fig 42)
The elertrocardiogram 17 uncomplicated Fusenmenger's com
plex In this not uncommon congenital heart lesion a dextropositiot
cf the aorta with a high interventiculas septal defect and dilated o

·71 ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS gram may show inverted T waves in two or more standard limb leads Right axis deviation has not been observed Depression of the ST segments may be marked (Fig 44) The electrocardiogram in pure pulmonic stenosis Pulmonic stenosis may be of valvular type in which the three semilunar cusps are fused or it may be infundibular in type where the pulmonary conus is involved in developmental arrest and is narrowed in either type right ventricular hypertrophy is present and usually appears in precordial leads of the electrocardiogram Right bundle branch block is not rare in this condition (Fig 45A and B) The electrocardiogram in fetralogy of Fallot In this common combined congenital lesion of the heart pulmonic stenosis is assoct ated with dettroposition of the aorta ventricular septal defect and right ventricular hypertrophy The electrocardiogram shows marked atnal and night ventricular hypertrophy The P deflections are large and pealed especially in lead 2 Q3 is usually prominent and the T waves are often diphasic or inverted in the standard limb leads Xwaves are high in V, and VR and the S deflections are deep over Vs and V8 positions First-degree a y Hock may be seen frequently in the tetralogy while higher degrees of a v block and bundle brand block are kss common (Fig 46A B and C) The electrocardiogram in transposition of the great ressels This anomaly is probably due to failure of normal rotation in the carly stages of heart development The pulmonary artery anses from the left venincl. and the aorta from the nght ventricle Life depends on associated lesions The electrocardiogram shows no characteristic Salas (Fig. 47) The electrocardiogram in tricuspts atresia There is an occlu Sion or hypoplasia of the tricuspid vake of infective or developmental Origin A nonfunctioning nghi ventricle and hypoplastic or atresic pulmonary artery are concomitant findings in this malformation To be compatible with life this lesion neyitably presents an associated lesion or lesions of which the most common is an atrial septal defect The electrocardiogram shows ainal and left ventricular hyper trophy Left axis deviation is usually but not always present depend (Text congrued on p 75) ·71 ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS gram may show inverted T waves in two or more standard limb leads Right axis deviation has not been observed Depression of the S-T segments may be marked (Fig 44) The electrocardiogram in pure pulmonic stenosis Pulmonic stenosis may be of valvular type in which the three semilunar cusps are fused or it may be infundibular in type where the pulmonary conus is involved in developmental arrest and is narrowed In either type right ventricular hypertrophy is present and usually appears in precordial leads of the electrocardiogram Right bundle branch block is not rare in this condition (Fig 45A and B) The electrocardiogram in fetralogy of Fallot In this common combined congenital lesion of the heart pulmonic stenosis is assoct ated with dertroposition of the aorta ventricular septal defect and right ventricular hypertrophy The electrocardiogram shows marked atnal and nght ventricular hypertrophy The P deflections are large and pealed especially in lead 2 Q3 is usually prominent and the I waves are often diphasic or inverted in the standard limb leads Rwaves are high in V, and VR and the S deflections are deep over Vs and Va positions First-degree a y Hock may be seen frequently in the tetralogy while higher degrees of a v block and bundle brand block are kss common (Fig 46A B and C} The electrocardiogram in transposition of the great ressels This anomaly is probably due to failure of normal rotation in the carly stages of heart development The pulmonary artery arises from the left ventncl. and the aorta from the nght ventricle Life depends on associated lesions The electrocardiogram shows no characteristic Silas (Fig 47) The electrocardiogram in tricusptl alreria There is an occlu sion or hypoplasia of the tricuspid vake of infective or developmental origin A nonfunctioning night ventricle and hypoplastic or atresie pulmonary artery are concomitant findings in this malformation To be compatible with life this lesion inevitably presents an associated lestor or lesions of which the most common is an atrial septal defect The electrocardiogram shows ainal and left ventricular hyper trophy Left axis deviation is usually but not always present depend (Test construed on p75) ·WYM, * Thi t: *** Put D. C The same patient with arm electrodes reversed and the leg electrole attiched to the right leg instead of the Jeft onc In this instance also the tracing is similar to that of D The true precordial leads VR and VR in this case seen in the three clectrode po itons AB and C notcu alors The three of tracings are alike 73 ·Lillo 12 VAN VW V! ? to 1 C The same patient with arm electrodes rescrsed and the leg electrole attached to the right leg instead of the Jeft one in this instance also the tracing is similar to that of D The true precordial leads VR and VR in this case seen in the three electrode po itons AB and C nolet alors The three types of tracings are alike 73 ·75 ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS ing on the position and rotation of the heart in the chest (Fig 48A and B) The electrocardiogram in anomalous placement of tricuspul talres (Flstein's disease) The posterior leaflet is displaced doun ward into the right ventricle Right atrial enlargement and tncuspid insufficiency are commonly present 'The electrocardiogram shows right atral hypertrophy with large and wde P waves and frequent conduction disturbances Paroxysmal tachycardia and premature contractions may be of frequent occurrence (Fig 49) The electrocardiogram in 10lated tentricular septal defects (maladie de Roger) The lesion is commonly high in the septum and ventricular hypertrophy is uncommon The electrocardiogram is usually noncontributory to the diagnosis of this lesion Large diphasic ORS complexes with components of equal size (hatz Wachtel sign) may occasionally be present in to standard limb leads but this sign is not pathognomonic and may disappear in the oldur child It is 27 interesting fact that conduction is so rarely affected in d.lects of the ventricular septum Even when the septum is absent as in cor bratratum inloculare or cor biloculare and where the post tion of the bundle and its branches is most irregular conduction is rarchy disturbed As the bundle develops before the development of thu septum it is unlikely to be affected by later appearing mal formations of the septum However complete or incomplete a v block does occur although rarely and bundle branch block also may be found in defects of the ventricular septum (Fig 50) The plectrocardiogram in single rensnicle with rudimentary outlet chamley (cor bratriatum inlorulare) There is a per sistence of the common ventricle and bulbus cordis owing to an early arrest of development of the heart One or both vessels may arise (Text continued on p 78) 1 Tracing shakisig Mirror wage in lead acrompanied by upright P waves In this led it On reversal of arm leads right becomes left axis deviation and 07 interchange of leads aV and av the heart is seep to be in a semihorizontal clectrocardiographic position The paixot sa 5 month old girl (RL) referred by Dr Edward Hardy The infant showed DD Canoss and was well rourished and developed Aa isolated derzocardia th persy teni leh aortic arch was present ·75 ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS ing on the position and rotation of the heart in the chest (Fig 48A and B) The electrocardiogram in anomalous placement of tricuspul ralres (Flstein's disease) The posterior leaflet is displaced down ward into the right ventricle Right atrial enlargement and tncuspid insufficiency are commonly present The electrocardiogram shows right atral hypertrophy with large and wide P waves and frequent conduction disturbances Paroxysmal tachycardia and premature contractions may be of frequent occurrence (Fig 49) The electrocardiogram in isolated tentricular septal defects (maladie de Roger) The lesion is commonly high in the septum and ventricular hypertrophy is uncommon The electrocardiogram is usually noncontnbutory to the diagnosis of this lesion Large diphasic ORS complexes with components of equal size (hatz Wachtel sign) may occasionally be present in to standard limb leads but this sign is not pathognomonic and may disappear in the older child It is 27 interesting fact that conduction is so rarely affected in delects of the ventricular septum Even when the septum is absent as in car bratriatum Irloculare or cor biloculare and where the post tion of the bundle and its branches is most irregular conduction is rarchy disturbed As the bundle develops before the development of thu septum it is unlikely to be affected by later appearing mal formations of the septum However complete or incomplete a v block does occur although rarely and bundle branch block also may be found in defects of the ventricular septum (Fig 50) The plectrocardiogram in single rensricle with rudimentary outlet chamler (cor Wiatriatum triſorulare) There is a per sistence of the common ventricle and bulbus cordis owing to an early arrest of development of the heart One or both vessels may arise (Text continued on p 78) [ Tracing shakisig Mirror wage in lead I acrompanied by upright P waves In this le dit On reversal of arm leads right becomes left axis deviation and or interchange of leads ay and av the heart is seen to be in a seriborizontal clectrocardiographic position The pala sa s month old giel (KL.) referred by Dr Edward Hardy The infant shoxes Do Canosis and as well rourished and developed As isolated desfocardia ich persz tepi leh aortic arch was present

·1
W
3
S
Creation
Fig 41B
这
w
F1g 42 Trzesas of 4-month-old syanolie infant (I de Conh dentrocardia,
11. Yesus and signis suggesting pulmonic stenosis as the maig leston The
standard limb Isads show marked deviation of the electrical atus to the left
choo teversal of the arm terminals (2) becomes marked right axis deviation
(Lead li should be tead fram tisht to left.)
77

·L
2
is
:
4
Fig 41B
...
Fig 42. Trzes36 of 4-month-old syanote infant (I de C) unh de trocardia,
Wu Yesus and sugnis suggesting pulmodic steriosis as the data lestan The
standard limb Isads show marked deviation of the electrical atis to the left
Whatod several of the am terminals (1) becomes marked right axis deviation
(Lead lx should be tead fram tight to left.)
77

·79
ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS
atal septal defect. The tracing shows evidence of right ventricular
hypertrophy and large P deflections especially in lead 2 are present
(Fig 52)
VA
W
Fig 44 From an electrocardiographic tracing described by Dr Paul A
de Sant Agnese ed as Case #2 (W!) in their excellent paper Glycogen
Storage Disease of the Hean Ppt - 41
NA

·79
ELECTROCARDIOGRAM IN CONGENITAL HEART LESIONS
atral septal defect. The tracing shows evidence of right ventricular
hypertrophy and large P deflections especially in lead 2 are present
(Fig 52)
.
Net
AC
TAR
DAN
I
V
Fig 44 From an electrocardiographic tracing described by Dr Paul A
di Sant Agnest Hol as Case #2 (WI) in their excellent paper Glycogen
Storage Disease of the Hean Pp. 27
M

·1:21 WM W. BE w LIFE WHIH ய பேபமமம் Fig 46 A Eletrocardiogram af 16- month-old boy (EN) with clinscal diagnosis of tetralogy of Fallot confirmed by autopsy Cyanosis and polycythemia were present A barsh systolic murmur was heard over the beart, loudest in the third left intercostal space The pulmonic second sound was di minished Under X ray examination the heart was seen to be boot shaped in the antero position view with a concavity noted on the area of the pulmonary arc and the great ves seis were of narrow width in this view The lune field 1m B Tracing of 7 year old boy Falot and night sortic arch sh rally was successtully anas tomosed 10 the left subclavian artery Marteł nght electrical and deviation with vertical electrocardiographic po- 81 ·WAY ora 4 SEN FwP JEDEN Fig 46 A Ele trocardiogram af 16- month-old boy (EN) with clinscal diagnosis of tetralogy of Fallot confirmed by autopsy Cyanosis and polycythema were present A barsh systolic murmur was heard over the heart, loudest in the third left intercostal space The pultonic second sound was di misisbed Under X ray examination the heart was seen to be boot shaped in the antero positsio view with a concavity voted on the area of the pulmonary arc and the great ves sets were of narrow width in this view The une field te B Tracing of 7 year old boy Falot and night Bot Bitb wh ja dy was successtully anas tomosed 10 the left subclavian artery Markel night electrical axis deviation with vertical electrocardiographic po- 81

·.
AF
mit
Katrit
It's nii:
14:
Fiz 48 A Tracing taken on a f moath-old girl (MH) who had shown
moderale generalized cyanosis since birth A harsh systolic murmur was heard
loudest over the third and fourth left intercostal spaces and was transmitted
oser the precordium and back A systolic thrill was palpable over the area
of maximum intensity The X ray studies showed an absence of the pulmonary
HTC giving a bootile cardiac shadow
The electrocardiogram is characteristic of right atrial and left veatricular
tyzacrtrophy Left aus devation sith horizontal electrocardiographic position
of the heart is present P deflections are large and pealed
83

·M
H-2
T
SATE
M
1
Ir
Fiz 48 A Tracing taken on a tonth-oid girl (MH) who had shown
moderate generalized cyanosis since birth A harsh systolic murmur was heard
loudest over the third and fourth left intercostal spaces and was transmitted
oser the precordium and back A systolic thrill was palpable oser the area
of marimum intensity The X ray studies showed an absence of the pulmonary
ac giving a bootile cardiac shadow
The electrocardiogram is characteristic of right atrial and left ventricular
tytcriophy Left aus densation sith horizontal clecirocardiographic position
of the heart is present P deflections are large and pealed
83

·antenor oblique view no left atral accentuation was seen on the barium filled esophagus Repeated clectrocardiograms showed as above the large and wide p waves in lead 2 typical of atrial hypertrophy There was no deviation of the electrical axis Arrhythmia has been a constant finding Short phases of status bradycardia, at SZ beats a minute vary with runs of atrial Parotysmal tachycardia with a rate of 158 per minute Frequently ectopic beals appear sinely Chinical diagnosis, Ebsteins disease 1 Tv L FIE 0. Tracing from a symptom free 6 year-old boy (RO) with ventricu lat sepial delect #ha showed a harsh high piched systolic murmur al third left intersca al space which had been noticed soce birth A systolic thrill was palpable in the same area X ray studies showed a norcaal heart outline The Flexitocardiog am shows sinus rhythm with a delay in conduction I waves are large 85 ·antenor oblique view no left atrial accentuation was seen on the barium filled esophagus Repeated electrocardiograms showed as above the large ud de P Waves in lead 2 typical of atrial hypertrophy There was no deviation of the electrical axis Arrhythmia has been a constant finding Short phases of status bradycardía, at SZ beats a minute vary with runs of atrial Parotysmal tachycardia with a rate of 158 per minute Frequently ectopic beals appear sinely Chinical diagnosis, Ebstcins disease wwwwwwwww ve . Fig. Tracing from a symptom free 6 year-old boy (RO) with ventricu las septal defect wha showed a harsh high piched systolic murmur al third left interscs al space which had been noticed since birth A systolic thrill was palpable on the same area X ray studies showed a normal heart outline The flexiyocardiog am shows sinus rhythm with oo delay in conduction I waves are large 85 ·cardiograph position Repeatedly tracings over the precordium and around the chest were of similar form a!tfough varying in voltage B Tracing of 4-month-old Chinese girl (CY) who entered the wards chucally all with pneumococcic meningitis No heart murmurs were noted tut the child was cyanatic and died soon after admission At autopsy a cor biatriatum triloculare was found The heart Heighed 40 gm and was triangular in shape The aorta arose from the main chamber to the right of a small pulmonary artery which originated in a rudimentary chamber A single atrioventricular Valve was present dividing the atria from the single ventricte A wide atrial-septal defect was present The standard limb lead tracing shows slight right axis deviation with elevation of the S-T segment in lead 2. 11 3 F12 57 Tracing fion 2 month old boy (IR) who was admitted to the wards in critical condition with marked cyanosis and dyspnea The Fran was markedly enlarged A harsh systolic murmur was present (al though at 4 weeks neither enlarge mert of the heart nor cyanosis had heca present) Post mortem examina Hon shoued marked hypertrophy and dilatio of the right ventricle All pulmonary veins emptied in!o the coronary sinus such opened into the dilate night atrium The valve of the foramen ovale was open on the right The tracing shows atral and right venirxular hypertrophy Marked right aus deviation with icrtical clectro cardiograph c heart position is present The P defections are high and wide especially so in lcad 2 R is of bigh amplitude in av PANTUN 87 ·cardiograph position Repeatedly tracings over the precordium and around the chef were of similar for altfough varying in voltage B Tracing of 4-month-old Chinese girl (CY) who entered the wards crucally all with pneumococcic meningitis No heart murmurs were noted tut the child was cyanatic and died soon after admission Af autopsy a cor biatriatum triloculare was found The heart Heighed 40 gm and has triangular in shape The aorta arose from the main chamber to the right of a small pulmonary artery which ongmated in a rudimentary chamber A single atrioventricular Valve was present dividing the atria from the single tentricte A ide atrial-septal defect was present The standard limb lead tracing shows slight right axis deviation with elevation of the ST segment in lead 2 MANSUN FI? 5? Tracing from 2 month old boy (IR) who was admitted to the wards in critical condition with marked cyanosis and dyspnea The Pran was markedly enlarged A harsh ystolic murmur was present (81 though at 4 weeks neither enlarge mert of the heart nor cyanosis had heen present) Post mortem examina Hon shoued marked bypertrophy and dilation of the right ventricle AN pulmonary veios emptied into the coronary sinus which opened into the dilated right atrium The valve of the foramen ovale was open on the right The tracing shows ainal and right nincular Rupertrophy Marked right 211 deviation with crtical clectro cardiograph c heart position is present The P deffections are high and wide specially so in lead 2 R is of bigh amplitude in av 87 ·89 RATE AND RHYTHMIS braun lesions especially those affecting the medulla It may be noted in bypothyroidism Sinus bradycardia is rare in the cardiac chid creept as a digitalis effect Sinus arrhythmia and sinus arrest are usual accompaniments of a slow heart rate (Fig 536} Sinus Arrhythmia Sinus arrhythmia is an irregularity of sinus rhythm in which the RR cycles vary more than 01 second The arrhythmia has no clinical significance and is common in the child especially so in those over 7 years of age (Fig 53d) Sinus Arrest Sinus arrest is an arrest of sinus rhythm in which a complete cardiac cycle is blocked or fails to appear The resultant pause almost equals two normal cycles The condition may be physiological and As not rare in the normal child (Fig 53e) Premature Contraction An abnormal heart contraction that anses from an ectopic focus and disturbs the regularity of the basic rhythm is a premature con iracuon Premature contractions may be of anal atroventricular nodal or ventricular origin They may be recognized in the eletrocardiogram both by their abnormal position in the cycle and by therr bizarre fom A compensatory pause may be seen following the ectopic systole There is no compensatory pause when the ectopic beat is interpolated in a slow thythm the prematurely contracted ventricle has then had time in which to tecover from 11s refractory period and is receptive for the arrival of the normal excitation impulse (Fig 16) Premature contractions of each type may be found in the normal infant and child although those of atrial form are the most usual They are also found in acute rheumatic fever and other infectious diseases and is typho d fever dunng the period of slow rate Premature contractions may also be present in con genital heun disease as in arial and incuspid valve anomalies although this finding is not as frequent as it is in the adult with an atrial septal defect ·RATE AND RHYTHMIS 89 brain lesions especially those affecting the medulla It may be noted in bypothyroidism Sinus bradycardia is rare in the cardiac child freept as a digitalis effect Sinus arrhythmia and suus arrest are usual accompaniments of a slow heart rate (Fig 53C) Sinus Arrhythmia Sinus arrhythmia is an irregularity of sinus rhythm in which the RR scles vary more than 01 second The arrhythmia has no clinical significance and is common in the child especially so in those over 7 years of age (Fig 530) Sinus Arrest Sinus arrest is an arrest of sinus rhythm in which a complete cardiac cycle is blocked or fails to appear The resultant pause almost quals two normal cycles The condition may be physiological and is not rare in the normal child (Fig 53e) Premature Contraction An abnormal heart contraction that anses from an ectopic focus and disturbs the regularity of the basic rhythm is a premature con tracuon Premature contractions may be of anal atroventricular nodal or ventricular origin They may be recognized in the electrocardiogram both by their abnormal position in the cycle and by therr bizarre form A compensatory pause may be seen following the ecopic systole There is no compensatory pause when the ectopic beat is interpolated in a slow thythm the prematurely contracted ventricle has then had time in which to recover from 118 refractory period and is receptive for the arrival of the normal excitation impulse (Fig 16) Premature contractions of each type may be found in the normal infant and child although those of atrial form are the most usual They are also found in acute rheumatic fever and other infectious diseases and is typho d fever dunng the period of slow rate Premature contractions may also be present in con genital hean disease as in atrial and incuspid valve anomalies although this finding is not as frequent as it is in the adult with an atrial septal defect ·RATE AND RIYTHVIS 91 Coupling or alternation of ectopic with regular contractions is not Tarc in children especially in those who have had recent pulmonary infections and during digitalis toxicity (Fig 546 and c) Atrial premature contractions Ectopic P waves are usually mented they appear prematurely and are followed by a P R interval that is not shortened Atrial premature contractions may be present in the normal child They may also appear in acute rheumatic fever and other infections They are occasionally seen in the child with congecutal heart disease (Fig 54a and b) 11 nodal premature contractions arise in the atrioventncular nodu and cause the P deflection by retrograde action to appear just before during or after the ORS complex which is of supraventricular type Nodal systoles may be found in the normal child s tracing as well as in those with acute rheumatic fever and other infections (Fig 540) 1 entricular premature contrachons anse in ectopic foci of the tentricle Thu QRS complex so formed is bizarre in outline resem blins somewhat the wide notched QRS curve of a blocked bundle branch The contraction may be of nght or of left ventricular origin and may be recognized as such in the standard lead i Jf the man QRS deflection m lead 1 is upnght the systole is of nght Ventricular origin of downward of left ventricular origin Although less common in the normal child than premature ssscals of supraventricular ongin ventricular premature contractions do occur in the child without cardiac pathology They are more frequent in children with acute infections especially of thelmatic arsd pulmonary etiology and in nephritic and endocrine disorders 11 < 1 Synus tachycaruis with Tale of 200 per minute in 8 month-old mile with acute infection Atrial and ventricular complexes and intervals ate of norma) outline Same in 6 year-old girl with her haan r c. Siaus Grad toy Heart rate : compler Low Us d Sious art Lull with joint pains" The P P intersals vary in length Sinus attest in normal 6 year old child There is a pause almost equal to the normal beats in which the heart is to receive stimulus from the normal pacemaker 1 ·RATE AND RIYTHVIS 91 Coupling or alternation of ectopic with regular contractions is not fare in children especially in those who have had recent pulmonary infections and during digitalis toxicity (Fig 546 and c) Atrial premeture contractions Ectopic p waves are usually mented they appear prematurely and are followed by a PR interval that is not shortened Atnal premature contractions may be present in the normal child They may also appear in acute theumatic fever and other infections They are Occasionally seen in the child with congecutal heart disease (Fig 54a and b) 11 nodal premature contracttons arise in the atroventncular nod and cause the P deflection by retrograde action to appear just before during or after the QRS complex which is of supraventricular type Nodal systoles may be found in the normal child s tracing as well as in those with acute theurgatic fever and other infections (Fig 54c) 1 entricular premature contrachons arise in ectopic foci of the kenttricic Thu QRS complex so formed is bizarre in Outline resem bline somewhat the wide notched QRS curve of a blocked bundle branch The contraction may be of right or of left ventricular origin and may be recognized as such in the standard lead 1 Jf the main QRS deflection in lead 1 is upnght the systole is of nght Venincular origin of downward of left ventricular origin Although less common in the normal child than premature 53560ks of supraventricular ongin ventricular premature contractions do occur at the child without cardiac pathology They are more frequent in children with acute infections especially of thelmadic arsd pulmonary etology and in nephriuc and endocrine disorders 1 r 1 Sinus tachycards with Tale of 200 per minute in 8 month-old male with acute infection Atrial and ventricular complexes and itcrvals are of Dorna) outline Same in 6 year-old girl with her haar C. Siaus brad boy Heart rate compler Low U d. Sinus art TE! with joint pains" The P P intervals vary in length Sinus attest in normal 6 year-old child There is a pause almost equal to the normal beats 10 which the bcant 31t5 to receive stimulus from the normal pacemaker 1 ¢ ·RATE AND RHYTHVIS 93 M للبدلا منڈیلا FES$ A, B Two cases showing Wenckebachs syndrome in 6 and 8 year old boys, respectively suffering with acute rheumatic carditis The P R inter vals increase in duration progressively until the P wave falls during a refractory period of the ventricle and is blocked. The following PR interval is of normal duration and the cycle us repeated C Atroventricular or nodal rhythm in a 6-year-old normal boy with acute upper respiratory infection P Waves are inverted, and the P R interval is short encu U naves are visible following the T deflections Paroxysmal a v thythm in 8 year-old girl showing cardiac asystole and occasional ventricular escape beat dunog ocular pressure (Case of Dr Alfred E. A V interference dissociation appeanng in an 11 year-old boy with rheumatic carditis (Case of Dr Herbert von Gal) The atria responding to the depressed SA node beat at a slower rate than that of the ventricles which react 10 ad ectopic focus in the a v bode or ventricle Langriann) A V rhythm may be present as a congenital anomaly of conduction and is usually of little clinical significance The thythm is often transı tors and the position of the P waye may tary in respect to the QRS complex especially in those cases where a v thythm is due to di stalls or o her toxic effect (Fig SSC and D) ·RATE AND RHYTHVIS 93 INT Les Site E گندل للسلام Fig S5 A, B Two cases showing Wenckebach s syndrome in 6 and 8 ycar of boys, respectively suffering with acute rheumatic carditis The P R inter vals increase in duration progressively until the P wave falls during a refractory period of the ventricle and is blocked. The following P R interval is of normal duration and the cycle is repeated C Atrioventricular or nodal rhythm in a 6-year-old normal boy with acute upper respiratory infection P waves are inserted, and the P R interval is short ened U waves are visible following the T deflections o Paroxysmal a v rhythm in 8 year-old girl showing cardiac asystole and otasional ventricular escape beat during ocular pressure (Case of Dr Alfred E. AV interference dissociation appeanng in an 11 year-old boy with rheumatic carditis (Case of Dr Herbert von Gal) The atria responding to the depressed SA node beat at a slower rate than that of the ventricles which react 10 ag ectopic focus in the a v sode or ventricle Langriann) A V thythm may be present as a concenital anomaly of conduction and is usually of little clinical significance The thythm is often transı tors and the position of the P wave may lary in respect to the QRS complex especially in those cases where a y rhythm is due to di stalls or o her toxic effect (Fig SSC and D) ·RATE AND RHYTHMS 95 M Fig 16 A First-degree a y blank of transitory duration The P waves are notched and widened The P R interval » 03. xoconu The PR segment is Towered (Case of acute sheumatic lever 1 B As in A Pwaves are superimposed on 7 deflections in 6 year-old child with a live carditis Ci Second-Jegree a v block Pand R waves fall regularly and PR inter rals are equal The first acrtal or p wave 17 cach cycle is hlocked by a re fractive ventricle giving a ? | degree of block Note the Ta nave (12yetted) following the second pdeflections Czt "The same child as aboic during pha e of 11 a y block Three Sear-old boy wah tepralogy of Fallot. The ST segment es Occasionally de preeu by a Ta wave D Complete a v block in 1! scar old boy with ventricular septal select Pwaves and R wiles fall regularly but bcat no selationship to on Brother The P R intervals are regular nole dunng its refractile stage when the ventricular response being blacked no QRS complex will appear The succeeding P deflection is followed by a normal P R inter al and the cycle of lacreasing a v condutton is repeated (Fig 55A and BI ·95 RATE AND RHYTHVIS مامایی میمه there was FUM Fig 16A First-degree a y blank of transitory duration The P Waves are notched and widened The PR interval us 03. second The PR segment is fouered (Case of acute sheumatic lever) B As in A P waves are superimposed on 7 deflections in 6 year-old child with a live carditis C1 Second-legrec a v block Pand R waves fall regularly and PR inter rals are equal The first atral or Wave in each cycle is hlocked by a re fractive entricle giving a degree of block Note the Ta wave (inverted) following the second P deflections Ct The same child as abosc during pha e of III av block Three Sear-old boy #ah tepralogy of Fallot. The S-T segment e Occasionally de preseu by a Ta wave D Complete a v block in 11 scar-old boy with ventricular septal efect P waves and R Wales fall regularly but bcat no relationship to SD Brothes The PR intervals FE iregular nole dunng 115 refractile stage when the ventricular response being blocked no QRS complex will appear The succeeding P deflection is followed by a normal PR internal and the cycle of lacreasing a v condution is repeated (Fig 55A and By

·95
RATE AND RHYTHVIS
LO
موبایل
Fig. 56 A Pirst-degrec a v block of transitory duration The P waves are
notched and widened The PR interval is 03. second The P'R segment 15
lowered (Case of acute rheumatic fever )
B As In A P waves are superimposed on T deflections in 6 year-old child
thuth active carditis
Ci Second-degree av block, P and R waves fall regularly and P R inter
tas are equat The first almal or p wave in each cycle is blocked by a re
ote the Ta wave (inverted)
21 11 a y block Three
Segment is occasionally de
Jised by a Ta wale
D Complete a block in an 11 year old boy with ventricular septal defect
waves and R waves fall tegularly but bcar no relationship to one another
The P R intervals are IrTC62}ar
node during its refractile stage when the ventricular response being
blo ked na QRS complex will appear The succeeding P deflection
15 followed by a normal PR interval and the cycle of increasing
3 y conduction is repeated (Fig 55A and B)

·95
RATE AND RHYTHUS
باب المنال
Fig. 56 A first-degrec a v block of transitory duration The P waves are
notched and wened The PR interval is 03. second The P'R segment is
lowered (Case of acute theumatic fever)
As In A P Waves are superimposed on T deflections in 6 year-old child
uth active cards
Ci Second-legrte a v block, P and R waves fall regularly and P R inter
as are equal The first anal or p wave in each cycle is blocked by a re
ste the Ta ware (inverted)
21 11 a v block Three
Segment is occasionally de
Josed by a Ta wave
D Complete a block in an 11 year old boy with ventricular septal defect
Pwaves and R waves fall tegularly but bcar no relationship to one another
The P R intervals are ITC94}ar
J
node during its refractile stage when the ventricular response being
blocked na ORS complex will appear The succeeding P deflection
is followed by a normal PR interval and the cycle of increasing
3 y conduction is repeated (Fig 55A and B)

·RATE AND RHYTHNIS 97 Of venencle beat at a more rapid rate QRS complexes appear more frequently and usually without relation to P waves however, normal conduction may appear for one or more cycles in the course of the rhythm (Fig. 55E) Atrial Paroxysmal Taclıycardia This is an abnormal transitory rhythm consisting of a phase of rupid atrial premature contractions which appear without pause regularly one after another The condition is occasionally seen in the new born in whom no clinical endence of cardiac disease can be found It may also be found in children with congenital heart disease especially in those with atrial and tricuspid leaflet anomalies in whom it may appear on effort or during acute infections it may occur in cases of short PR interval or Wolf Parkinson White syndrome It is not common in acute rheumatic fever although it play occur (Figs 26 49 [L2 and 3) and 570) Atrtoventricular Modal Paroxysmal Saclscardia This is an ectopic regular rapid rhythm with its origin in the av node P waves may precede or fall upon or follow the supraventncular type of QRS complexes which are dominant The tachy Cardia may appear in a normal child and no cause may be found It may be seen in children with congenital heart disease and in those with short PR conduction time (Figs 55D and 57D) Ventricular Paroxysmal Tachycardia This is an abnormal tachycardia which onginstes in the ventricle and consists of a succession of rapid and almost regular ectopic Senincular beats The rhythm is very rare in the child especially in those under 10 years of age It may appear in the rheumatic cardiac Mith widespread myocardial damage and rarely in congenital cardiacs (I 1g 578) Itrial Flutter Arrial Putter is a disorder of atnal conduction in which there are abnormal rapid and regular atrial contractions with a rate averaging ·RATE AND RHYTHVIS 97 or ventrcle beat at a more rapid rate QRS complexes appear more frequently and usually without relation to P waves hou ever, dormal conduction may appear for one or more cycles in the course of the rhythm (Fig. SSE) Atrial Paroxysmal Taclıycardia This is an abnormal transitory rhythm consisting of a phase of tipid atrial premature contractions which appear without pause regularly one after another The condition 15 occasionally seen in the new born in whom no clinical endence of cardiac disease can be found It may also be found in children with congenital heart descase especially in those with atral and tricuspid leaflet anomalies in whom it may appear on effort or during acute infections It may occur in cases of short PR interval or Wolf Parkinson White syndrome It is not common in acute theumatic fever although it may occur (Figs 26 49 [L2 and 3) and 570) Atrioventricular Modal Paroxysmal Sachycardia This is an ectopic regular rapid rhythm with its origin in the a v node p waves may precede or fall upon or follow the supraventncular type of QRS complexes which are dominant The tachycardia may appear in a normal child and no cause may be found it may be seen in children with congenital heart disease and in those with short PR conduction lime (Figs 55D and 57D) Tentricular Paroxysmal Tachycardia This is an abnormal tachycardia which originates in the ventricle and consists of a succession of rapid and almost regular ectopic Senincular beats The rhythm is very rare in the child especially in those under 10 years of age It may appear in the rheumatic cardiac with widespread myocardial damage and rarely in congenital cardiacs (I 1g 578) Itrial Flutter Atrial Putter is a disorder of atrial conducion in which there are abnormal rapid and regular atrial contractions with a rate averaging ·99 RATE AND RHYTHMS common in atrial Autter seen in infancy Various degrees of block may be present in the same patient The condition is rare in the child although many of the tachycardias found in the newbom are due to this condition and it may occasionally occur in the child with advanced mitral disease or in Cases with hypertrophy and dilatation of the night atrium as in Ebstein s disease The electrocardiogram shows toothlike regular atrial Autter waves which follow one another without pause and silhout respect to the ventricular responses which fall segularly usually with a 1 2 1 3 or 1 4 or mixed degree of block Flutter or i waves are best seen in leads 2 and 3 and in Vi and V (Fig 573) Itrial Fibrillation Atrial fibrillation is a completely irregular heart action in which the atri are in a constant state of rapid irregular, and ineffectual motion and in which ventricular response is also irregular in force and shythm Atrial activity is represented in the tracing by unequally sized and spaced small "E waves P waves are absent and the QRS complexes vary in voltage and appearance (Figs 21 25 and S7A) Anal fibrillation is rarely seen in the child It may be present in severe thermalc carditis especially in those children who have grcally enlarged hearts and miltal lesions The rhythm may be paroxysmal or transitory in type and may appear as a sign of digitalis toxicity when it will disappear on the temoval of the drug It may also occur as a transient finding in typhoid fever and diphther and has been found on embolization of a coronary artery from vegetative endocarditis Ventricular Fibrillation Fibrillanon of the ventricles is a grave disorder of the heartbeat in *hich the ventricles contract with total irregularity of force and rate The electrocardiogram shons large rapid irregular oscillations of ·RATE AND RHYTHS 99 common in atrial futter seen in infancy Various degrees of block may be present in the same patient The condition is rare in the child although many of the tachycardias found in the new bom are due to this condition and it may occasionally occur in the child with advanced mitral disease or in cases with hypertrophy and dilatation of the night atrium as in Ebsteins disease The electrocardiogram shows toothlike regular atrial futter waves which follow one another without pause and shout respect to the ventricular responses which fall regularly usually with a 1 2 1 3 or 1 4 or mixed degree of block Flutter or waves are best seen in leads 2 and 3 and in Vi and V (Fig 57B) Itrial Fibrillation Atral fibrillation is a completely irregular heart action in which the atria are in a constant state of rapid irregular, and ineffectual motion and in which ventricular response is also irregular in force and shythm Atrial activity is represented in the tracing by uncqually sized and spaced small " waves P waves are absent and the QRS complexes vary in voltage and appearance (Figs 21 25 and 57A) Ainal fibrillation is rarely seen in the child It may be present in severe theumauc carditis especially in those children who have grcally enlarged hearts and mitral lesions The rhythm may be paroxysmal or transitory in type and may appear as a sign of digitalis toxicity when it will disappear on the removal of the drug It may also occur as 3 transient finding in typhoid fever and diphthem and has been found on embolization of a coronary artery from vegetativc endocarditis Tenircular Fibrillation Fibrillation of the ventricles is a grave disorder of the heartbeat in which the ventricles contract with total irregularity of force and rate The electroxardiógram shor's large rapid irregular oscillations of ·Appendut Boys Asc 3 4 Number of Cases 9 18 24 29 5 6 7 8 9 10 11 Average 013 013 0 14 013 014 014 013 014 0 14 0 14 Standard Dentation 004 003 009 002 009 00? 001 001 001 004 Range 01-015 010-0 16 0 12-017 011-017 011-019 010-0 18 0 10-016 0 10-0 18 012-016 012-018 31 33 19 13 Girls Number of Cases Aeroge Standard Delarion Range 3 1 $ 8 9 2 33 29 35 30 6 18 1 9 013 017 013 014 014 014 014 014 014 001 009 001 007 001 002 007 007 009 010-016 010-0 16 012-0 16 011-0 16 019-016 012-016 012-016 012-0 16 012-0 16 11 1 Table 8 Showing average PR intervals without reference to heart rate found in a study of normal school children 3 to 13 years of age at 1 101 ·Appendur Boys 48€ 3 5 6 7 8 9 Number of Cases 9 18 24 29 33 31 33 27 19 13 Average 013 0 13 014 013 0 14 0 14 013 014 0 14 014 Standard Devtation 004 003 009 002 002 00? 001 001 001 004 Range 019-015 010-016 0 12-0 17 011-017 011-019 010-018 010-016 0 10-0 18 012-0 16 012-0 18 Girls Number of Cases Aeroge Standard Deslation Range 3 4 6 7 8 22 33 29 35 30 6 18 71 9 013 017 013 014 014 014 0 14 014 014 001 002 001 007 001 0 02 007 002 009 010-016 010-0 16 0 12-0 16 011-616 019-016 012-016 012-016 012-016 0 12-0 16 10 12 Table 8 Showing average P R intervals without referepce to heart rate found in a study of normal school children 3 to 13 years of Ace Stat 101 ·APPENDIX 103 704 ec Cycle length Square root 06635 046 0678 0 $8 6692 050 0707 os 0722 0.33 0727 034 0735 056 0749 058 0760 060 0775 063 0787 064 0800 0 66 0812 068 080$ 070 0835 07 0855 074 0866 076 0870 078 0882 080 0895 087 0905 084 0915 086 09.7 088 0935 0950 1 16 1 06 108 Tabte 11 Approximate square roots of cycle lengths for use in determilding QTc values 040 Enthoven's Triangle In an electrical sense the sight shoulder the left shoulder and the left hip form an equilateral triangle in the frontal plane around the heart The heart thus lies approximately equidistant from each of the three points in the relatively homogeneous substance of the body The complicated pathway of electrical activity passing through the heart on atrial or ventricular activation may be reduced to a single sector which may be calculated from any two of the three standard leads by Einthoven s formula * or simply by using Ein thosens inangle which is a more crude but useſui method (Fig 59) Tangens of alpha where alpha equal dhe angle between the axis and honzonia) e the Ampliude in d. Ilmeters of the QRS *ave in lead and hat of QRS in leads Te length of the axis or the manifest pocentral difference i calculated trora cos la-60- ·APPENDIX 103 066 Cycle length Square root 704 ec 06635 046 0678 $8 0692 050 0707 05 0722 0.33 0727 054 0735 056 0749 0 58 0760 060 0775 063 0787 064 0800 0812 068 0815 070 0835 07 0855 074 1866 0870 078 0 882 080 0895 087 0905 684 0915 086 09.7 088 0435 090 0950 1 06 1 16 108 Tabte 11 Approximate square roots of cycle lengths for use in determining QTc values 076 Einthoven's Triangle In an electrical sense the sight shoulder the left shoulder and the left hip form an equilateral triangle in the frontal plane around the heart The heart thus lies approximately equidistant from each of the three points in the relatively homogeneous substance of the body The complicated pathway of electrical activity passing through the heart on atrial or ventricular activation may be reduced to a siogic sector which may be calculated from any two of the inree standard leads by Einthoven s formula * as simply by using Ein thosens inangle which is a more crude but useſui method (Fig 59) Tangent of alphas where alpha equals ahe angle between the axis and honzontal e tbc ampliude in Ilimeters of the QRS kave in lead and that of QRS in leads The length of the axus or the manifest potential difference i calculated (cora cos 12-60-1 73 ·APPENDIX 105 amplitudes in millimeters of R3 and S, from the sum of R, and Sa PD White suggests that if this index measures over 30 mm abnormal left axis deviation is present with normal border line of 20 to 30 if it measures under -15 mm abnormal night axis deviation is present with a normal border line of --- 10 to 15 ·APPENDIX 105 amplitudes in millimeters of Rg and S from the sum of R, and Sg PD White suggests that if this index measures over 30 mm abnormal left axis deviation is present with normal border line of 20 to 30 if it measures under -15 mm abnormal night axis deviation is present with a normal border line of 10 to 15 ·BIBLIOGRAPHY 107 Burliger Aurt "Observations on the Duration of the Electrical Systote of the Heart," am Heart J 7 189 1931 Bland E F White PD and Garland J "Congenital Anomalies of the Coronary Artenes Report of an Unusual Case Associated with Cardiac Hypertrophy Am Heart J 8787-801 1933 Broan IV Congenstal Heart Disease Staples Press, Inc New York 1939 Caffey John Pedioine X ray Dragnosis Year Book Publishers Inc Chucio 1945 Campbell Jonn s Stereoscopic Radiology of the Coronary System" Quart I Med., 22 254 1929 Campbell VB "Congenital Heart Block" Heart 5 15 1943 Chapman C and Gibboo T "Dertrocardia Isolated " Am Heart 3 39 507 1950 Clement D and Godman C "Glycogen Disease" | Pedro 36 11 1990 de Sant Agnese F A Anderson DH and Mason HH "Glycogen Storage Disease of the Heart, Pediatrics 6 402 1950 Drawe C Harkesburg E and Ashmat R. Childrens Electrocardiograms Produced by Rbeumatic and Congenital Heart Disease Am ) Dis Child 53 1470 1937 Dry Thomas Afanual of Electrocardiography 2nd ed WB Saunders Company Philadelphia, 1950 Ebstern Nathan "The Heart in Normal Infants and Children " J Pediat 32 39 1948 Enthoven "Weiteres uber das Elektrokardiogramm," Arch I dres Physiol 512 517 1908 Erathoven W La determination de lare electnque du coeur Acta pediat 4136 1925 Feldman William Dextrocardia with Upngbt P 10 lead 1" Bri Child Dis 22 136 1925 France Richard The Large Q Wave in Lead 3 of the Electrocardiogram Am J M Sc 187 16 1934 Freireich AW and Nicolson GHB "A Rare Electrocardiographic Finding Occasionally Seen is Sungle Ventrcle Hearts, Am Ileart I 33 526 1952 Gardberg 1 and Ashman, R "The QRS Complex of the Electro cardiogram Arh Ini Ated 72 210 1943 Goldberger E A Simple Method of Determinag Abnormalities of the QT Interval" Am Heart] 36 141 1948 Unrpolar Lead Electrocardiography Lco & Febiges Philadelphia 1949 ·BIBLIOGRAPHY 107 Burhager Aurt "Observations on the Duration of the Electrical Systole of the Heart," Am Heart] 7 189 1931 Bland E F White PD and Garland J "Congenital Anomalies of the Coronary Artenes Report of an Unusual Case Associated with Cardiac Hypertrophy Am Heart J 8787-801 1933 Bron IV Congenstal Heart Disease Staples Press, Inc New York 1919 Caffey John Pedialne X ray Diagnosis Year Book Publishers Inc Chica o 1945 Campbell Johns Stereoscopic Radiology of the Coronary System Quart Mcd., 22 254 1929 Campbell VB "Congenital Heart Block" Heart 515 1943 Chapman C and Gibboo T "Dextrocardia Isolated" Am Heart 3 39 507 1950 Clement D and Godman C "Glycogen Disease" J Pedrol 36 11 1990 de Sant Agnese IA Anderson DH and Mason HH "Glycogen Storage Disease of the Heart, Pediatrics 6 402 1950 Drawe C Harkesburg E and Ashmat Ra Childrens Electrocardiograms Produced by Rheumatic and Congenital Heart Disease Am ) Das Child 53 1470 1937 Dry Thomas Afanual of Electrocardiography 2nd ed WB Saunders Company Philadelphia, 1950 Ebsteig Mathan "The Heart in Normal Infants and Children" Pediat 32 39 1948 Eindhoven weiteres uber das Elektrokardiogramm," Arch I dges Physiol 512 517 1908 Exachosen W La determination de lare electnque du coeur Acta pediar 4 136 1925 Feldman William "Dextrocardia wh Upngbt P 10 Lead 1" Brut Child Dis 22 136 1925 France Richard The Large Q Wave in Lead 3 of the Electrocardiogram" Am MSc 387 16 3934 Freireich AW and Nicolson GHB "A Rare Electrocardiographuc Finding Occasionally Seen is Sungle Ventncle Hearts, Am treart I 13 526 1952 Gardberg Vand Ashman, R "The QRS Complex of the Electro cardiogram Arh Ini Mied 72 210 1943 Goldberger E A Simple Method of Determining Abnormalities of the QT interval" Am Heart ! 36 141 1948 Unrpolar Lead Electrocardiography Leo & FeDiges Philadelphia 1949 ·BIBLIOGRAPHY 109 Linetzky S Die Beziehungen der Form des Elektrokardiogramms zu dem lebensalt der Hertzgrosse und dem Blutruck 2tschr 1 esper Path u Therap 9 699 1911 Littman, David "Ventricular Strain and Ventncular Hypertrophy" New En lond J Med 9 263 1947 VcCullough Hub and Wilson William Chronic Adhesive Pericarditus American Pediatric Society May, 1929 Mcllichael John "Extensive Visceral Fndartentis Obliterans in a Young Child" Arch Dis Child 22 165 1929 Was bester P.and White PD "Dextrocardia with Situs Inversus Am Complicated by Hypertensive and Coronary Heart Disease Heart) 15 493 1918 Mannheimer Edgar Calbrated Phonocardiography and Electrocardiography a Clinical Statistical Study of Normal Children and Children wich Congenital Heart Disease" Acta pediat (Supp 2) 28 1 1940 Marorey Vind Rantz L A "Electrocardiograms in 679 Healthy Intants and Children" Pediaines 5 396 1950 Klaster A. M Dachs S and Jaffe HL "The Precordial Lead of the Electrocardiogram of Normal Children, Am Du Child 53 1000 1937 Marachyrhi V "Le Cardiogramme des Nourrissons Nourrisson 17 95 1945 Nurnaghan D McGinn S and White PD Cor Pulmonale Heart J 25 373 1943 Nicolax H and Fun4ro R "Das Elektrokardiogram des Sauglings * Zerrull i Physiol 22 58 1908 (Funaro R. d Eletrocardio- Bramma dell Adulto e del Bandino Riv di chn pediat 8 480 1910 ) Micolson GX 8 Shulman HI and Green DL "Congenital Heart Block Am I Dis Child 37 580 1929 Chapter on "Electrocardiography in Children" in Clinical Ped africs Vol 18 Appleton-Century-Crofts Inc New York 1910 Coaretation of the Aorta in a Child with Arrested Subacute Bactens} Endurteritis and a Caicified Mycotic Aneury m at the Seat of Sinchure Am Heart] 20 357 J940 Heegeroth CT Das Elektrokardiograrome schwachliche Saughags, Zische kind 6 396 1913 Mosh PH and Bames AR "Electrocardiographic Changes Associated With Pencard 13" An Int Afed 65 291 1940 Orgair ES Marun M and Anderson IIG "Electrocardiographic Alterations in Rheumatiu Fever in Children Am ) Dis Child 62 26 1941 ·BIBLIOGRAPETY 109 Linetzky S Die Beziebungen der Form des Elektrokardiogramms zu dem lebensalt der Hertzgrosse und dem Blutruck 2tschr 1 esper Path u Therap 9 699 1911 Littman, Dand "Ventricular Strain and Ventncular Hypertrophy" New En lond J Mest 9 363 1947 VaCullough Hub and Wilson William Chronic Adhesive Pericarditis Amencan Pediatric Society May, 1929 Mcl fichael John "Extensive Visceral Fndartentis Obliterans in a Young Child" Arch Dis Child 22 165 1929 Hao bester P., and White PD "Dextrocardia with Situs Inversus Am Complicated by Hypertensive and Coronary Heart Disease Heart J 15 493 1978 Mannheimer Edgar Calbrated Phonocardiography and Electrocardography a Clinical Statistical Study of Normal Children and Children wich Congenital Heart Disease" Acta pediat (Supp 2) 28 1 1940 Marorey Vind Rantz L A "Electrocardiograms in 679 Healthy Intants and Children Pediatrics 5 396 1950 Klaster A. M Dachs S and Jaffe HL "The Precordial Lead of the Electrocardiogram of Normal Children, Am I Dus Child 53 1000 1937 Marachyile V "Le Cardiograthme des Nourrissons Nourrisson 17 95 1945 Murnaghan D McGinn S and White PD Cor Pulmonale Heart] 25 373 1943 CO2 H and Fun 4ro R "Das Elektrokardiogram des Sapplings Zenault | Physiol 22 58 1908 (Fubaro R d Eletrocardio Bramma dell Adulto e del Bandico" Riv dt chn pediat 8 480 1910 ) Nicolson GX 8 Snulman HI and Green DL Congenital Heart Block Am I Dis Child 37 580 1929 Chapter on "Electrocardiography in Children" 10 Clinical Ped africs Vol 18 Appleton-Century-Crofts Inc New York 1970 Coarelation of the Aorta in a Chid with Arrested Subacute Bactens} Endurteritis and a Caicified Mycouc Aneury m at the Seat of Sinchure Am Heart] 20 357 3940 degeroth CT Das Elektrokardiogramme schwachliche Saughngs, Zische kind 6 396 1913 Mosh PH and Bames AR "Electrocardiographic Changes Associated With Pencad15" dret Int Afed 65 291 1940 Orgoin ES Marun M and Anderson IG "Electrocardiographic Alterations in Rheumati, Fever in Children * Am ) Dis Child 62 26 1911 ·BIBLIOGRAPHY 111 Sheldon Wilfred "Rheumatic Carditis with Complete Heart Block Proc Roy Soc Med 22 638 1929 Shepard Edward and Stewart Harold 'The Electrocardiogram in Dittrocardia with Situs Inversus Am Heart 1 36 52 1949 Slater SR Involvement of Coronary Arteries 10 Acute Rheumauc Fever" Am J Med Sci 181 203 1931 Sloer M and Berezovsky MR Electrographic Changes and Valvular Discase in Rheumatism of Children Prensa méd argent 32 2309 1945 Sokolov NE The Electrocardiogram in the Diagnosis of Acute Rheu matic Fever California Med 66 221 1947 Sokolow Maurice and Edgar Archie Unipolar Leads in Congenital Heart Disease Am Heart I 40 232 1950 Sokolow M and Friedlander RD "Normal Unipolar Precordial and Unipolar Limb Leads Am Heart I 38 665 1949 Soloft LA Anomalous Coronary Arteries Arising from the Pulmonary Artery Report of Cases in Which Left Coronary Artery Arose from the Pulmonary Artery Am Heart] 24 118-127 1942 Standardizauon of Precordial Leads Am Heart 1 15 107 and 235 1938 Switzer J 1 and Besoain M Unipolar Chest and Limb Leads in Children Am I Dis Chuld 79 449 1950 Tandfer J Anatomie des Her ens ed 3 Gustav Fischer Jena 1913 P 122 Taran L M "Laboratory and Clinical Criteria of Rheumatic Cardins in Children Pediat 29 71 1946 Taran L.M and Szilagyi N "The Duration of the Electrical Systole (QT) in Acute Rheumatic Carditis is Chidren am Heart J 33 14 1947 Taussig HB Congenital Malformations of the Heart Commonwealth Fund New York 1947 Tudbury P and Atkinson D The Electrocardiograms of 100 Normal Infants and Children 3 Pediat 36 461 1950 Tung Chen Lang "Duration of Electrical Systole in Cases of Massive Pericardial Effusion Am Heart] 22 35 1941 Uhley Milton The Electrocardiogram in Congenital Heart Disease Ann Int Ved 33 188 1950 Van Der Veer IB and Norns, RF Electrocardiographic Changes in Acute Pericarditis Clinical and Pathologic Study * Am Heart] 1431 1937 Weiss VM Electrocardiogram in Children with Chronic Rheumatic Heart Disease and Heart Failure" Am I Dis Chald 42 1339 1931 ·BIBLIOGRAPHY 111 Sheldon Wilfred "Rheumatic Carditis with Complete Heart Block Proc Roy Soc Med 22 638 1929 Shepard Edward and Stewart Harold 'The Electrocardiogram in Dettrocardia with Situs Inversus Am Heart ) 36 52 1949 Slater SR Involvement of Coronary Arteries Acute Rheumauc Fever" Am J Med Sci 181 203 1931 Sloer M and Berezovsky MR Electrographic Changes and Valvular Disease in Rheumatism of Children Prensa méd argent 32 2309 1945 Sololow The Electrocardiogram in the Diagnosis of Acute Rheu matıc Fever Calfornia Med 66 221 1947 Sokolow Maurice and Edgar Archie Unipolar Leads in Congenital Heart Disease Am Heart J 40232 1950 Sokolov M and Fredlander RD "Normal Unipolar Precordial and Unipolar Limb Leads Am Heart I 38 665 1949 Soloft LA Anomalous Coronary Arteries Arising from the Pulmonary Artery Report of Cases in Which Left Coronary Artery Arose from the Pulmonary Artery Am Heart I 24 118-127 1942 Standardization of Precordial Leads Am Heart J 15 107 and 235 1938 Switzer J1 and Besoain M Unipolar Chest and Limb Leads in Children Amy Dis Chuld 79 449 1950 Tandfer J Anatomie des Her ens ed 3 Gustav Fischer Jena 1913 P 122 Taran L M "Laboratory and Clinical Criteria of Rheumatic Cardins in Children Pediat 29 77 1946 Taran L.M and Szilagyi N The Duration of the Electrical Systole (QT) in Acute Rheumatic Carditis is Children" am Heart) 33 14 1947 Taussig H B Congentral Malformations of the Heart Commonwealth Fund New York 1947 Tudbury P and Atkinson D The Electrocardiograms of 100 Normal Infants and Children Pediat 36 461 1950 Tung Chen Lang "Duration of Electrical Systole in Cases of Massive Pericardial Effusion Am Heart] 22 35 1941 Uhley Milton The Electrocardiogram in Congenital Heart Disease Ann Int Med 33 188 1950 Van Der Veer SB and Norns, RF Electrocardiographic Changes in Acute Pericarditis Clinical and Pathologic Study" Am lleart I 131 1937 Weiss VM Electrocardiogram in Children with Chronic Rheumatic Heart Disease and Heart Failure" Am I Dis Child 42 1339 1931 ·INDES Age aus deviation and 18 Atrial septal defect (Cont) coronary circulation and 39 40 atrial fibrillation and 63 68 heart position and 16 atrial hypertrophy in 37 66 67 hcart rate and 12,4 101 102 bundle branch block and 33 34 67 inttisoid defection and 8 13 28 76 Pwidth and 1 2 44 hatz Wachiel sign and 59 64 66 PR interval and 2 3 4 101 102 67 QRS complex and 8 P Waves in 63 QRS interval and 9 parorysmal tachycardia and 97 QT interval and 11 12 right ventricular hypertrophy in 63 unipolar precordial leads 27-32 67 Anema and ventricular infarction 42 Atrial T Wave 3 90 95 Aortic atresia, 59 ST segment and 14 Aortic insufficiency bundle branch AV block 94 block and 33 complete 81 95 96 rheumatic heart disease and 44 51 digitalis and $3 54 94 Aortic stenosis 60 incomplete 94 congenital 60 interference dissociation 93 96 left axis deviation in 37 quinidine cffect of 56 left ventricular hypertrophy in 60 theumstic fever and 43 94 Arborization block 33 35 Wenchebacks syndrome and 93 94 Arteriosclerosis 40 AV dissociation 96 and coronary artery 40 congenital heart lessons in 81 Ashmans formula, 12 interference 93 96 Atrial fibrillation 99 Theumatic carditis and 44 atral septal defect 18 63 68 AV nodal paroxysmal tachycardia digitalis and 54 99 97 quinidine and 54 A V nodal premature contraction 91 rheumatic fever in 43 44 55 92 Atrial flutier 97 99 digitalis and 34 in neu born 99 rheumatic carditis in 44 Atrial hypertrophy 37 66 67 71 95 A V nodal thythm 92 93 atrial septal defect and 63 P waves in 274 93 P waves in 4 37 60 66 Atr1o-ventricularis communis 64 86 Ainal paroxysmal tachycardia 97 98 87 atrial septal defects in 63 Augmented unipolar leads 23 Fhsteins disease in 75 Avitaminosis effect on QT interval 1) quinidine and 54 56 Aris deviation 56 16 18 104 Wolft Parkin on White syndrome effect of deep inspiration on 5 6 and 36 in mitral stenosis 44 Atrial premalure contraction 91 9 Theumatic card is in 44 Bayley's triaxial reference system 18 Atnal septal defect 63 66 67 Bazetts formula 12 aortic atre 13 and 59 Bicuspid aortic valve 61 63 113 ·INDET Age aus deviation and 18 Atrial septal defect (Cont) coronary circulation and 39 40 atrial fibrillation and 63 68 heart position and 16 atrial hypertrophy in 37 66 67 heart rate and I 2,4 101 102 bundle branch block and 33 34 67 intiasioid defection and 8 13 28 76 P width and 1244 hatz Wachiel sign and 59 64 66 PR interval and 2 3 4 101 102 67 QRS complex and _8 P Waves in 63 QRS interval and 9 paratysmal tachycardia and 97 QT interval and 11 12 Tight ventricular hypertrophy in 63 unipolar precordial leads 27-32 67 Anemia and ventricular infarction 42 Atrial T Wave 3 90 95 Aortic atresia, 59 ST segment and 14 Aortic insufficiency bundle branch A V block 94 block and 33 complete 81 95 96 rheumatic heart disease and 44 SI digitalis and 53 54 94 Aortic stenosis 60 incomplete 94 congenital 60 interferencc dissociation 93 96 left axis deviation in 37 quinsdine effect of 56 left ventricular hypertrophy in 60 rheumsc fever and 43 94 Arborization block 33 35 Wenchebacks syndrome and 93 94 Arteriosclerosis 40 AV dissociation 96 and coronary artery 40 congenital heart lessons in 81 Ashmans formula, 12 interference 93 96 Atrial fibrillation 99 Theumatic carditis and 44 ainal septal defect 18 63 68 A V nodal paroxysmal tachycardia digitalis and 54 99 97 quinidine and 54 A V nodal premature contraction 91 rheumatic fever in 43 44 55 92 Atrial flutier 97 99 digitalis and 34 10 new born 99 rheumatic carditis in 44 Alrial hypertrophy 37 66 67 71 95 A V nodal rhythm 92 93 atrial septal defect and 63 P waves in 274 93 Pwaves in 4 37 60 66 Atrio-ventricularis communis 64 86 Ainal paroxysmal tachycardia 97 98 87 atrial septal defects in 63 Augmented unipolar leads 23 Fhsteins disease in 75 A vitaminosis effect on Q Tinterval 11 quinidine and 54 56 Avis deviation 5 6 16 18 104 Wolft Parkin on White syndrome effect of deep inspiration on 5 6 and 36 111 mitral stenosis 44 Atrial premature contraction 91 9 rheumatic card is in 44 Bayley's triaxial reference system 18 Atrial serial defect 63 66 67 Bazetts formula 12 aortic atre 13 and 59 Bicuspid aortic valve 61 63 113 ·INDEX 113 Irtranicou deflection 8 12. 13 28 Pware (cor 9 60 dettrocardia and 70 7 73 aze and, 8 13 18 9 31 diphask I 19 91 bundle branch block and, 13 33-35 inverted, 1 19 37 40 92 fatio ot nht to iete, 33 19 38 limb leads in 22:36 I to n. 7-3. rheumatic fever and 2, 43 44 50 Ventricular hypertrophy 37-39 set and 19 20 slurred 2 Tor juregion, 13 superimposed on T Wave 81 % Jelly contact (footnote) 78 wijih or 244 PR interval 3 2 Wa Ls igo 18 age and ? 34 atral septal defect 10, 59 64 66 67 congenital heart and 4 81 95 96 ventrxular septal defect in, 59 digitals and 53 diphtheria myocarditis ant. 4 Lutembacher syndrome 67 68 heart size and 3 pulse rate and 3 tot 1ean electrx axis 18 104 theumatic carditis and 4 43 95 Mitral stenosis atrial fibrillation and Wolff Parkinson White syndrome 16 99 PR segment 4 atrial futter and 99 superimposed Ta Wave 95 atrial hypertrophy and, 37 44 totic effect, atrial septul defect with, 67 68 Pancitas fibrocystic disease of 52 bundle branch block and 33 Pardee wave 15 ventricular hypertrophy and 38 44 Paroxysmal tachycarðra 97 The monocardiogram of Mann see also Arrial AY nodal and Myocardial infarction, sre also Ven Venit, ular tricular myocardial infarction digitalis and 54 chemia and, 42 48 50 65 quanidine and 54 46 Wolf Pathiason White syndrome Acoplastic invasion a v block and 36 Periartentis nodo a 40 of coronary system 40 Pericarditis 45 71 Nephris, acute, 50 54 acute theumatis 43 45 32 and premature contractions 91 constrictive 89 49 53 renfor atrial flutter in 99 effusion and 48 atis deviation and 18 ST segment displacement and 47 congenital heart discase and 57 48 S coronary Circulation in 39 Precordial unipolar leads 27-32 I my leguts att in pseudo single ventricle heart 83 Paroxysmal tachycardia in 9 84 f Hayes in 14 10 single Yentricle heart 78 86 unsrafat Chet Icads +1-7 Pre 19)ng co zept Premature contractions 89 See also Atrial A V and Ventricu anscht 51 $$ 98 99 uge variation 1 2 4 atrial septal defect and, 63 97 atral hypertrophy and congenital heart disease and, 89 OT coupling and 91 92 atral parorysmal tachycat lia and 98 digitalis apu 54 av thythm and -93 interpolated 40 89 rheumatic carditis and 44 89 $ 37 71 ·INDEX 115 Irtfon icon dettection 8 12. 13 28 Pwane (Cor) 960 dettrocardia and 707 73 aze and, 8 13 18 9 31 diphask. I 19 I: tundle branch block and, 13 33-35 inverted, 1 19 37 40 92 fatio ol n to iete, 33 29 3R limb leads in 22-26 I to 3-3. rheumatic fever and 2,3 44 58 entrycular hypertrophy 37-39 set and 19 20 slurred ? or juration, 13 superioposed on T wave 819 Jelly contact (footnote) 78 wijih of 1244 PR interval 3 hat Was I gt 18 age and ? 3 4 atral serial defect in, 59 64 66 67 congersital heart and 4 81 95 96 ventrxular septal defect in, 59 digurdss and 53 diphtherine myocantils anul 4 Luterbacher syndrome 67 68 heart size and 3 pulse rate and 3 101 teat clecinc axis 18 104 Theumatic carditis and 4 43 93 Miral sienosys ainal fibrillation and Wolst Parkinson Vite syndrome 16 99 PR segment 4 atrial Rutter and 99 Superimposed Ta nave 95 atrial hypertrophy and, 37 44 totic effect atrial septal defect with, 67 68 Pancitas fibrocystic disease of $2 bundle branch block and 33 Pardee wave 15 entricular hypertrophy and 38 44 Paroxysmal tachycardia 97 The morocardiogram of Mann1 see also Atrial AV nodal and Myocardial wlarction, see also Ven Venit, ular tricular myocardial infarction digitalis and 34 Lchemia and, 42 48 50 65 quanidine and 54 46 Wolff Parkipson White syndrome Acoplastic invasion av block and 36 $ Periartentis nodo a 40 of coronary system 40 Pericarditis 45 97 ephris, acute, 50 54 acute rheumatic 43 43 52 and premature contractions 91 consinctive 8 9 49 53 Henborn atrial flutter in 99 effusion and 48 atis deviation and 18 ST segment displacement and 47 congetual heart discase and 57 4% 5 coronary clculation in 39 Precordial unipolar Icads 27-32 Jy leau's arts in pseudo single ventricle heart 83 Parotismal tachycardia in 9 ** t waves in 14 in single ventricle heart 78 86 unipolar chet Icads 11-7 Pre 19ns ceert & 12 Premature contractions 89 See also Atrial AV and Ventricu absent 51 95 98 99 age Variation 1 2 44 atrial septal defect and, 63 99 atrial hypertrophy and $ 37 71 congenitat heart incase and, 89 coupling and 91 92 atral parouysmal tachycat 113 and 98 digitalis and S4 av rhythm and interpolated 40 89 93 rheumatic carditis and 44 89 ·INDEX 117 Sex Com Tricepsd insufficiency and nsht ven OT interval and it fricular hypertrophy 38 T waves and 14 Tricu pid stenosis atrial hypertrophy Shock spus tachycardia in 88 IN 37 ventricular 17Carchion and 47 left Seduncular hypertrophy 37 Sickle cell anemia 32 Truncus arteriostis communis 6 65 Single ventricle heart, 75 78 85 Tubersclerosis 40 precordial leads aod 28 and coronary occlusion 40 pseudo triloculate heart, 83 and premature contractors 92 Saus arrest 89 90 Suus anbythmia 89 V wave 15 90 93 set and 21 Unipolar limo }eads 17 2 Sinds bradycardia 88 90 busdie branch block and 34 35 Ta wave and 90 Saus thythm 88 Ventricular bypertrophy and 37 39 Wolff Parkinson White syndrome in age and rate 2 3 4 109 36 Srus tachycardia 88 90 in rheumatic carditis 4* Standard limb Ycads 3 17 22 23 V lead 18 9 and anatomic position of heart 37 V, icad 3 Dead ! 22 lead 31 Icad z 23 V lead 32 Sead 3 2 V lead 32 und sex 3 V lead 32 10 ventricular hypertrophy 37-39 VE lead 25 26 48 Stokes Adams syndrome 96 VL lead 24 Sobarire bacterial endocardusis and VR lead 23 burdle branch block 33 Vectorcardiograto of Wilson 19 Subapthe stenosis 6) 67 Ventricular aneurysm 42 0 bundle branch block 33 62 Ventricular asystole 96 Hentricular fibrillation 99 100 *** 14 15 digitalis and 53 constructive pericardus and 49 in theumatic feier 43 degrcalis effect on, 53 Ventri ular gradient 18 escoger storage areast 23 79 Ventricular hypertrophy 37-39 44 Nyersion of 14 23 31 49 49 60 71 limb and precotdral Stads in 72 aorke stenosis and 37 6D alfial septal defect and 3 6 67 myocardial infarcut, and 15 ** congenital Deart lesson and 57 42 66 nephritis and 50 intrinsicax deflection in 13 Theumatic carditis and 43 QT interval in 1 sex and 190 rheumst, heart disease and 44 Hentricular hypertropby and 14 Ventricular myocardial infarcida 39 To wave 3 90 95 antmia and 42 Tetralogy of Fallot, 71 81 sthal fibrillation : 99 Transition zone afrial hypertrophy and 37 10 ventricular hypertrophy 37 bundie branch biock and, 42 Transportation of great vesselt 71 coronary artery in, 40 $ coronary anomaly and 42 65 66 in igie ventricic heart 73 ischesnia and, 42 Trxes dairesia 71 $3 84 shock 4.8 42 ·INDEX 117 Sex (Com Tricepsd insufficicacy and pght yen OT interval and it tricular hypertrophy 38 Twives and 14 Yticu pid stenosis atrial hypertrophy Shock snus tachycardia in 88 IN 37 ventricular 17archion and 47 left seduricular hypertrophy 37 Sickle cell anemi32 Truncus arteriastix communis 67 68 Single ventricle hcart, 75 78 85 Tubersclerosis 40 precordial leads aod 28 and coronary occlusion 40 pseudo triloculate heart, 83 and premature contractions 92 Siaus arrest 89 90 Stus anbyihmia 89 V wave 15 90 93 Sex And 21 Unipolas ob jeads 17 29 Sinds bradycardia 88 90 bundie branch block and 34 35 Ta wave and 90 Ventricular hypertrophy and 37 39 Saus rhythm 88 Wolf Parkinson White syndrome in age and rate 2 3 4 107 36 Snus tachycardia 88 90 in rheumatic carditis 4* Standard limb Icads 3 17 22 23 V lead 8 9 aod anatomic position of heart 27 V, lead 31 lead I zz lead 31 Icad 2 23 V lead 32 Sead 3 25 V lead 32 and sex V lead 32 10 ventricular hypertrophy 37-39 VT lead 25 26 48 Stokes Adams syndrore 96 Vl. lead 24 Sobarite bacterial endocardusis and VR lead 23 burdle branch block 33 Vectorcardiogram of Wilson 19 Subaothic stenosis 6) 67 Ventricular aneurysm 42 200 bundle branch block 33 62 Ventricular asystole 96 entricular fibrillation 99 100 digitalis and 53 constructive pericardis and 19 20 theumatsc fever 43 digrcalis effect on, 33 Ventri ular gradient 18 glycogen storage disease 23 79 Ventricular hypertrophy 37-39 47 inversion of 14 23 31 49 49 60 71 limb and precordial Itads at 12 2011k stenosis and 37 6D 3. airial septal defect and 3 6 67 myocardial infarclion and is *t congenital heart lesson and 57 42 66 72 nephritit and 50 intrascord deflection in 13 Theumatic cardit13 and 43 QT interval in 11 ser and 190 theunsti heart disease and 44 ventricular hypertropby and 14 Ventricular myocardial infarchon 39 Tx wave 3 90 95 antmi and 42 Teiralogy of Fallot, 71 81 Athal fibrillation in 99 Transition zone 7 afrial hypertrophy and 37 11 Vestricular hypertrophy 33 hingle bragch block 3id, 42 Transportation of great vessel 71 coronary artery in, 40 3 coronary anomaly and 42 65 66 17 32gle ventricle heart 75 ischemia and, 42 Trxu natrosia 71 83 84 shock and 42

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