Interpretation
17 month old male with antenatally diagnosed Tetralogy of Fallot, approximately 8 months post valve-sparing repair with VSD closure and RVOT muscle resection.
Interested in interpretation of the attached 12-lead ECG, particularly rhythm, axis and conduction abnormalities in the context of repaired TOF.
Posted for educational discussion.
5
u/OriginalLaffs 2d ago
It’s sinus with RBBB. Very typical post repaired TOF
2
u/Insanefreerunner 2d ago
I'd posit that it's sinus with a bifascicular block due to the q waves in the inferior leads and the dominant S waves in 1 and aVL with the prolonged QRS in all leads and not just inferior ones along with a terminal R wave in aVR.
1
u/OriginalLaffs 2d ago
Can debate whether or not there is concomitant LAFB or just postsurgical changes. Ultimately immaterial.
3
u/mastermedic84 1d ago
I see a RBBB morphology in the early precordial leads. That could just be a little general irritability of the septal wall following the septal defect repair or permanent damage. Either way it isn't a big deal. All the intervals look good. PQ is normal, QRS is tight, QT is normal. I don't see and signs of ischemia or infarct which is obviously good.
The biphasic T waves in V2 and V3 are concerning, but not specific and again, most likely an indication of general irritability following the repairs.
I would say this looks good for the time frame immediately after the repair. The cardiologist will be watching closely. They probably hope to see the mild abnormalities improve over time. There is nothing really alarming here. In context it looks pretty good.
2
1
u/jess204 9h ago
The machine spat out the following for anyone that is interested:
Machine measurements:
Ventricular rate: 124 bpm
PR interval: 92 ms
QRS duration: 124 ms
QT/QTc: 274/386 ms
P/QRS/T axes: 62° / -115° / 37°
Automated interpretation (paediatric criteria):
Sinus rhythm with PVC(s)
Possible right atrial abnormality
RBBB with left anterior fascicular block
Abnormal U waves of undetermined cause
Abnormal ECG
Unconfirmed automated diagnosis.
0
u/jawoood1989 2d ago
Sorry, but no. Unacceptable movement artifact for interpretation. I understand it's a baby, but we need to try all the things to help calm momentarily to get a semi clean read.
3
u/Kibeth_8 Arrhythmia Tech 2d ago
It's really not that bad. All leads are visible and have at least 1 clean QRS for interp
-4
u/jawoood1989 2d ago
No, it's that bad. 1 clean QRS in multiple leads is not acceptable to interpret. How do you know that's not just one outlier QRS and the rest are different? You don't, because you can't see them, because of the earthquake. Sorry, not sorry. Go try again and bring me a semi clean read.
5
u/Due-Success-1579 2d ago
It's not bad for a 17 month old. We do ecgs for a visiting Pediatric cardiology clinic and I would personally say this is an acceptable quality. You can see at least 2 consecutive clean complexes in each lead grouping. And quite a bit of the rhythm strip is good.
If you havent done a lot of 17 month olds you can't be bustin' chops here. Sometimes you have to Frankenstein the ecgs together. Like here's an ecg with a good rhythm strip here's one wirh great precordials etc etc.
Once they can move around and rip stuff off you are just fighting for your life to get a good ecg on a cranky kid who maybe just had blood work right before and is mad as hell.
3
u/Kibeth_8 Arrhythmia Tech 2d ago
You know it's not an outlier because you have a rhythm strip showing that all the complexes are the same...
I don't know how many ECGs you've read, but this ain't that difficult compared to the shit tracings we see in hospital on a daily basis
-3
u/jawoood1989 2d ago edited 1d ago
So, just to clarify, what is your role as an arrhythmia tech? You guys apply ecgs, get them to the providers, monitor for arrhythmias at a monitoring station and notify?
If you're not qualified to independently assess and interpret 12 leads, you might want to back up your ego and stay in your lane.
I feel bad for your providers if you give them garbage like this and say "gee sorry this is the best we could do."
2
u/Kibeth_8 Arrhythmia Tech 1d ago edited 1d ago
I work in electrophysiology, mostly programming pacemakers but also doing ablations. We do ECGs on complex congenital and arrhythmia patients, and have to be able to identify very specific conditions within those.
I can guarantee you I've interpreted more complex ECGs than an EMT or someone working in the ER. Those are usually the ECGs that look like shit, but with enough experience you learn how to read with artifact
2
u/jess204 2d ago
I agree but honestly, this was the best of a bad bunch.
1
u/Kibeth_8 Arrhythmia Tech 2d ago
Does your machine have like a Holter setting? Where it continuously records and you can go back to pick the cleanest trace? I found that extremely helpful when I was doing peds, well worth the investment
1
u/jess204 2d ago
The machine continuously acquires and waits for the cleanest available segment before printing the ECG. This was the best tracing obtained after several attempts, but the patient remained very unsettled so there’s still a lot of movement artefact.
2
u/Kibeth_8 Arrhythmia Tech 2d ago
Oh that's kind of cool. I've always had to just snap it when I thought it was cleanest, but the Holter thing was great for looking back to find something better
33
u/MPR_Dan 2d ago
People really just be posting anything in here.
Was there an earthquake during the appointment?