Biventricular Hypertrophy

Biventricular Hypertrophy

Hypertrophy of both left and right ventricles.

The ECG has a low sensitivity for the diagnosis of biventricular hypertrophy (BVH), as the opposing left and right ventricular forces tend to cancel each other out.

  • There may be signs of both LVH and RVH on the same ECG — e.g. positive diagnostic criteria for LVH with some additional features suggestive of RVH.
  • The Katz Wachtel phenomenon — large biphasic QRS complexes in V2-5. This is the classic ECG pattern of BVH, most commonly seen in children with ventricular septal defect (VSD).

In the presence of LVH – Additional signs indicating RVH:

  • Right atrial enlargement.
  • Right axis deviation.
  • Tall biphasic QRS complexes in multiple leads.
  • Deep S waves in V5-6.

In the presence of RVHAdditional signs indicating LVH:

  • Tall R waves and deep S waves in V2-5.
  • QRS amplitude > 50 mm.

Katz-Wachtel phenomenon

  • Large biphasic QRS complexes (tall R waves + deep S waves) in V2-5.

ECG Examples
Example 1
ECG Dilated cardiomyopathy Biventricular hypertrophy

Biventricular hypertrophy:

  • Katz-Wachtel phenomenon — large biphasic QRS complexes in V2-5.
  • LVH: Voltage criteria for LVH (S V2 + R V5 = 35 mm, R aVL > 11 mm) with signs of LV strain (T-wave inversion in V4-6).
  • Persistent S waves in V5-6 suggestive of associated RVH.

Example 2
ECG Biventricular hypertrophy Katz-Wachtel phenomenon

Biventricular hypertrophy

  • Katz-Wachtel phenomenon — biphasic QRS complexes in the precordial leads.
  • Enormous voltages — QRS amplitude > 50 mm in V2.
  • Easily meets voltage criteria for LVH and there are associated features of LV strain (ST depression / T-wave inversion in V4-6).
  • Signs of right atrial enlargement — peaked P waves in lead II.

Example 3

Biventricular hypertrophy in a child with VSD:

  • Katz-Wachtel phenomenon – large biphasic QRS complexes in V2-5.
  • Enormous QRS voltages.
  • Right axis deviation and T-wave inversion in V1-3 are normal findings on the paediatric ECG.

References


Advanced Reading

Online

Textbooks


LITFL Further Reading

ECG LIBRARY 700

ECG LIBRARY

Electrocardiogram

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

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