Associated symptoms

Ventricular Hypertrophy A. QRS axis is usually directed towards hypertrophied ventricle B. Voltage criteria (varies with age (see table)) and R/S morphology; look at V1 and V6 1. Right Ventricular Hypertrophy (RVH) a. Tall R wave in V1 and deep S wave in V6 b. Upright T wave in V1 (in>4 day old infant and <8 year old child) c. qR in V1 or V3R d. Pure R in V1 or V3R e. RSR’ in V1 with tall R’ (volume overload)

2. Left Ventricular Hypertrophy (LVH) a. Tall R wave in V6 and deep S wave in V1 b. Deep, > 4mm, narrow Q wave in V6 or inferior lead except III

3. Biventricular hypertrophy (BVH) a. Positive criteria for both RVH and LVH b. Katz-Wachtel phenomenon: R+S V3 > 60 mm

CHEST X-RAY (CXR) Heart size and silhouette A. Cardiothoracic ratio (CT ratio); see appendix 1. Relation of largest transverse diameter of the heart and the widest internal diameter of the chest (A + B/ C) 2. Normally < 0.6 in newborns and < 0.5 in children B. Cardiac chambers (see appendix) C. “Classic” heart silhouettes 1. Boot-shaped; TOF, Tricuspid atresia 2. Egg-shaped; TGA 3. Snowman sign; supracardiac Total Anomalous Pulmonary Venous Connection (TAPVC) Pulmonary vascular markings A. Increased pulmonary blood flow (PBF) 1. Pulmonary arteries enlarged and extend into lateral third of lung field 2. Increased apical vascularity 3. External diameter of RPA>internal tracheal diameter B. Decreased pulmonary blood flow (PBF) 1. Hilum appears small 2. Remaining lung fields appear dark 3. Vessels small and thin C. Pulmonary venous congestion 1. Hazy and indistinct margins of pulmonary vessels 2. Kerley’s B lines a. Short, transverse strips of increased density best seen in costophrenic sulci b. Caused by engorged lymphatics and interstitial edema Definition = a non-invasive diagnostic modality which uses ultrasound to define cardiac anatomy and assess cardiac function.

Two-dimensional (2D) echocardiography A. Provides a cross-sectional or topographic view of the heart B. Demonstrate cardiac structures and relationships within the image plane

Doppler echocardiography A. Combines the study of cardiac anatomy with blood flow profile B. Direction and velocity of blood flow through structures C. Important applications 1. Estimates pressure gradients a. Across stenotic valves, regurgitant lesions, or shunt lesions b. Uses simplified Bernoulli equation: Gradient (mmHg) = 4 x (maximum velocity)² 2. Prediction of intra-cardiac and intravascular pressures a. RV or PA systolic pressure (SP) i. Based on tricuspid regurgitation (TR) velocity RV SP = 4 x (TR velocity)² + RA pressure (~10 mm Hg) ii. Based on VSD velocity RV SP = systemic SBP - 4 x (VSD velocity)² iii. Based on PDA velocity PA SP = systemic SBP - 4 x (PDA velocity)² b. LVSP based on aortic stenosis (AS) velocity LVSP = 4 x (AS velocity)² + systemic SBP 3. Ventricular function including tissue Doppler

Color Flow Mapping A. Color coded Doppler/ flow signal superimposed on two-dimensional images B. Red=flow towards transducer; Blue=flow away from transducer (purity varies with increasing velocity) C. Important applications 1. Adjunct to 2D imaging for defining anatomy 2. Defining shunts 3. Defining valvular stenosis and regurgitation 4. efining vessel obstruction

M-mode A. “Ice-pick” view of the heart B. Important applications 1. Measurement of the dimensions of cardiac chambers and vessels, thickness of the ventricular septum and free walls