This ECG shows signs of right ventricular enlargement, right atrial enlargement, and right axis deviation in a 20-year-old male with a known history of congenital heart disease. The ECG findings include tall peaked P waves in lead 2, predominantly positive P waves in V1, and an S1S2S3 pattern. Based on these criteria, along with the right axis deviation and clock-wise rotation, the diagnosis is tetralogy of Fallot.

1. ECG OF THE WEEK Prof.VIJAYARAGHAVAN‘S UNIT B.Elavazhagan.

2. A 20 YEAR OLD MALE, A KNOWN CASE OF CHD PRESENTED TO THE opd.

3. ECG

5. ECG

6. Summary of the findings Rate – 120/min Sinus rhythm Tall peaked P wave in lead 2 Predominantely positive P wave in V1 PR interval- 0.16 s, QRS Complex –0.12 s, ST ,T normal; Extreme right axis

7. Contd………. QRS configuration – V1 shows RS complex; abrupt change to rS in V2; leads V3-V6 shows rS complexes aVR shows qR complex. Lead 1 shows deep S wave Lead 2 & 3 shows S waves

8. INFERENCE Right ventricular enlargement Right atrial enlargement Right axis deviation S 1 S 2 S 3 pattern

9. Criteria FOR RVH SOKOLOW LYON CRITERIA : R V1 + S V5/V6 > 1.1 mv BUTLER LEGGET CRITERIA : Tallest R /R’ in V1 + deepest S wave in LEAD 1 /V6 – s wave in V1 > 0.7 mv OTHER FEATURES; -RIGHT AXIS DEVIATION ,CLOCKWISE ROTATION -RBBB PATTERN ,R: S > 1 IN V1 ,R /R ‘ > 5 mm P WAVE AXIS > 60 DEG – ACQUIRED HEART DISEASE UPTO 60 DEG –CONGENITAL HEART DISEASE

10. Differential diagnosis for s1 s2 s3 pattern with rvh COPD –P axis > 70 ; low voltage QRS in precordial leads Endocardial cushion defects –QRS north west axis LAHB deep S in lead 2 > lead 3; VSD with PHT –LVH with RVH right axis deviation; Complete TGA – av block and other heart blocks ;

11. Contd………. Isolated pulmonary stenosis /atresia— RVH with S1 S2 S3 pattern but deep T wave inversion present in addition Triology of fallot – LAE ,widening of P wave Tetrology of fallot – - RVH , RAE , S1 S2 S3 PATTERN , right axis deviation around 120 – 150 degrees -Rs pattern in V1 abrupt change to rS V2 and subsequent leads T inversion may be seen in V1 ,but not in others

12. diagnosis Since the ecg of our patient has 1.RAE 2.RVH 3.RIGHT AXIS DEVIATION 4.S1 S2 S3 PATTERN 5.CLOCK WISE ROTATION THE DIAGNOSIS IS “TOF”

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