(1)
Pediatric Cardiology, Policlinico S.Orsola-Malpighi, Bologna, Italy
Fig. 8.1
(a) Two-month-old baby boy with hiccups . The first abnormal QRS complex simulates a PVC; the others are more clearly artifacts due to hiccups. So they are neither supraventricular nor ventricular beats. They are simply subventricular. Phrenic, if you prefer. (b) Close-up
Fig. 8.2
As in the previous figure, the ECG shows an infant with hiccups . Unlike the previous case, there are also real PVCs (asterisk). The “subventricular” beats are quite rhythmic (arrows)
Fig. 8.3
(a) Infant on high-frequency oscillatory ventilation (HFOV) for diaphragmatic hernia. Some leads are consistent with atrial flutter with 3:1 or 2:1 A:V ratio. Diagnosis (and therapy) is easy: turn off the HFOV just a moment. (b) Close-up. (c) Another similar case
Fig. 8.4
Nine-year-old boy. The notched T wave in V3 may simulate a blocked P wave. The irregular rhythm due to the sinus respiratory arrhythmias can corroborate this deception
Fig. 8.5
Five-year-old girl admitted with breathing difficulties . (a) The ECG shows pathological ST-T changes in the precordial leads. On questioning the nurse, it emerged that the ECG was taken with the girl almost orthostatic in the arms of the mother. (b) The ECG was then repeated in a standard manner and was normal. As a rule, faced with a puzzling or pathologic ECG, it is always wise to enquire about the environment and the situation in which the ECG was recorded
Fig. 8.6
(a) One month old. At a glance, it seems an artifact from hiccups. (b) A and B are two different QRS complexes in the “same body.” It is a case of conjoined twins, joined at the abdomen
Fig. 8.7
(a) Eleven-year-old boy. A case of heart transplant . (b) The tiny waves (arrows) are the P waves of the remnant of the “old” sick heart
Fig. 8.8
(a–c). Three cases of adolescents with pectus excavatum (PEX) . Many different features of this condition have been described, from RBBB to unusual rotation in the horizontal plane. In these cases, pseudo-pathological P waves can be noted. In (b) the P wave is very bizarre and meets the criteria for significant left atrial enlargement. Once again, it is wise, when faced with “odd” features, to ask about chest deformities or other conditions know to alter the ECG
Fig. 8.9
(a, b) Two patients who underwent the Nuss procedure for PEX. The stainless steel bar placed in the chest produces this interesting artifact. In the precordial leads from V3 to V6, it is possible to find small R waves , concave ST elevation, and large J waves. (c) Close-up: a sort of Brugada on the left side! The “wrong” Brugada, the bartender said
Fig. 8.10
(a) Twenty years old with TGA who underwent Senning operation. The sinoatrial dysfunction (extensive atrial scar) was treated with an AAI PMK. (b) Close-up: the bipolar spike is very small
Fig. 8.11
(a) Sixteen-year-old male. HCM underwent an ICD implant as secondary prophylaxis after a cardiac arrest. The ICD also works as a VVI PM. After a sinus arrest, the device, that has no atrial sensing, releases a ventricular spike despite a late P wave. (b) Close-up
Fig. 8.12
(a) Ten-year-old female, neonatal complete AVB treated by pacing since birth. She developed pacemaker syndrome with severe left ventricular impairment . A biventricular pacing system (cardiac resynchronization therapy) was implanted. The PMK works in DDD: the atrial activity is sensed and followed by a double ventricular spike. (b) Close-up
Fig. 8.13
(a) Two-year-old boy affected by complete AVB , treated with epicardial DDD PMK. The lower rate is set at 50 bpm. When the spontaneous atrial rate is >50 bpm, the PM works in atrial sensing – ventricular pacing. (b) When the atrial rate is <50 bpm works, the PM stimulates both atrium and ventricle
